Legal Living Will Template for New Jersey

New Jersey Living Will

This Living Will is designed in accordance with the New Jersey Advance Directives for Health Care Act. It serves as a legal document to specify the type of medical care desired if the individual becomes unable to make decisions due to a terminal condition or permanent unconsciousness.

Personal Information

Full Name: ___________________________

Date of Birth: ________________________

Address: ______________________________

City: _______________ State: NJ Zip: _________

Phone Number: _________________________

Directive

I, _____________, being of sound mind, hereby direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choices indicated below, should I become unable to make my own health care decisions.

1. Life-Prolonging Treatments

   If I am in a terminal condition or permanently unconscious, I direct the following (initial one):

   _____ Administer all life-prolonging treatments, including artificially provided food and water.

   _____ Do not administer life-prolonging treatments if they only prolong the process of dying or my state of permanent unconsciousness. This includes artificially provided food and water, except as needed for comfort care.

2. Pain Relief

   I desire to receive medication or other treatment to alleviate pain, even if it hastens my death, as long as my decision does not intentionally cause my death.

3. Other Wishes

   (Herein, you may describe any additional wishes regarding your health care. Attach additional pages if necessary.)

Designation of Health Care Representative

I designate the following individual as my Health Care Representative to make health care decisions for me when I am incapable of making them myself.

Name: _________________________________

Relationship: __________________________

Phone Number: _________________________

Alternate Representative (optional):

Name: _________________________________

Relationship: __________________________

Phone Number: _________________________

Organ Donation (Optional)

I wish to donate only the following organs/tissues: ________________________________

or

I wish to donate any organs/tissues needed.

Signatures

This document is executed this ____ day of __________, 20__, in the presence of the undersigned witnesses, who affirm that the declarant is known to them, signed this document in their presence, and appears to be of sound mind and free of duress.

Declarant's Signature: ______________________________

Date: ____________________________________________

Witness 1 Signature: ______________________________

Printed Name: ____________________________________

Date: ____________________________________________

Witness 2 Signature: ______________________________

Printed Name: ____________________________________

Date: ____________________________________________