New Hampshire Living Will Template
This Living Will is designed to be in compliance with the New Hampshire Advance Directives Law (RSA 137-J). It is a legal document that outlines the preferences for medical treatment of the person named below in situations where they are unable to make decisions for themselves due to incapacitation. This document only becomes effective under the conditions specified by New Hampshire state law.
Personal Information
Full Name: ___________________________
Address: _____________________________
City: _______________ State: NH Zip Code: _________
Date of Birth: ________________________
Phone Number: ________________________
Statement of Desires for Medical Treatment
I, _______________ [Full Name], being of sound mind, hereby direct that my health care providers and family or other individuals who may be responsible for my care, make health care decisions in accordance with my desires as stated below. In the event that I am unable to communicate my desires myself, the following wishes shall guide the provision of my care.
- Preference regarding the use of life-sustaining treatment if I am in a condition that is terminal and irreversible:
a) I wish to receive all available life-sustaining treatments, including artificial nutrition and hydration.
b) I do not wish to receive life-sustaining treatment, with the exception of the following treatments: ________________.
- Preference regarding the use of life-sustaining treatment if I am in a state of permanent unconsciousness:
a) I wish to receive all available life-sustaining treatments, including artificial nutrition and hydration.
b) I do not wish to receive life-sustaining treatment.
- Other preferences about my health care (e.g., pain relief, hospitalization, hospice care, etc.):
____________________________________________________________________________________.
____________________________________________________________________________________.
Designation of Health Care Agent
If I am unable to make my own health care decisions, I designate the following individual as my health care agent to make health care decisions for me. This person will have the authority to make all health care decisions for me, in accordance with my wishes, including decisions about life-sustaining treatment:
Name of Health Care Agent: _________________________
Relationship to Me: _______________________________
Address: _________________________________________
City: ________________ State: NH Zip Code: _________
Phone Number: ___________________________________
Signature and Acknowledgement
I understand the purposes and effects of this document and I voluntarily sign this Living Will on this day__________ of _______________, 20____.
Signature: ___________________________
Print Name: __________________________
State of New Hampshire
County of ____________________
On this day, personally appeared before me, ______________________ [Notary Public/Justice of the Peace], the person known to me (or proved to me on the oath of _______________________) to be the person whose name is subscribed to the within instrument and acknowledged that (s)he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_____________________________________
Notary Public/Justice of the Peace
My Commission expires: _______________