$23.95

Add to cart

New Hampshire ____________________ Official Capacity _________________________________ 2 e by _________________________________________, declarant ___________________________________, and ___________________________________, witnesses on ____________________ Signature____________________nister oaths in the place of execution, who shall not also serve as a witness, and who shall complete and sign a certificate in content and form substantially as follows: Sworn to and signed before m (Witness Signature) _____________________________________________ (Witness Signature) The affidavit shall be made before a notary public or justice of the peace or other official authorized to admi of my knowledge, at the time of the signing the declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence. _____________________________________________the purposes expressed, or expressly directed another to sign for him. 2. Each witness signed at the request of the declarant, in his presence, and in the presence of the other witness. 3. To the bestitnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows: 1. The declarant signed the instrument as a free and voluntary act for _____________________ (Declarant's Signature) Print Name: ________________________________ Address: ___________________________________ ___________________________________________ We, the following wreatment and accept the consequences of such refusal. 1 I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. _____________________ng the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right to refuse medical or surgical t___________________________________________________________________ ____________________________________________________________________________ In the absence of my ability to give directions regardirtificial nutrition and hydration will be provided and will not be removed.) Additional Instructions (optional): ____________________________________________________________________________ _________uthorize that artificial nutrition and hydration not be started or, if started, be discontinued. (Yes) _______ (No) ______ (Circle your choice and initial beneath it. If you do not choose "yes,'' aze that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I have given under this section, I a, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care. I realianently unconscious condition and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawnined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized or that I will remain in a permreby declare: If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by 2 physicians who have personally exam _________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do heonal. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this ___ day of ___ (month, year). I,ation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax conseque nces arising out of this document should be discussed with a tax professiime to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situse or as to their legal effect or completeness. Living Will Information & Instructions ­ Page 3 [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from talth care provider or such provider's employee. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purponowledged pursuant to the provisions of RSA 456 or RSA 456-A. If the person making the document is a resident of a health care facility or patient in a hospital, no more than one witness may be the he person acting under the direction or control of the attending physician or any other person who has at the time of the witnessing thereof any claims against the estate of the person, and shall be ack forth in RSA 137-H:3 shall be executed by the person making the same in the presence of 2 or more subscribing witnesses, none of whom shall be the person's spouse, heir at law, attending physician orf participating in decisions about his care, and it may be, but need not be, in form and substance substantially as follows: (see form below) Section 137-H:4 Execution and Witness. ­ The document setno lifesustaining procedures be used to prolong his life when he is in a terminal condition or is permanently unconscious. The document shall only be effective if the person is permanently incapable oluids by eating and drinking. Section 137-H:3 Living Will. ­ A person of sound mind who is 18 years of age or older may execute at any time a document commonly known as a living will, directing that he following: nasogastric tubes; gastrostomy tubes; intravenous feeding or hydration; and hyperalimentation. It shall not include sustenance. IX. "Sustenance'' means the natural ingestion of food or ficia of consciousness are absent as determined by the attending physician and a consulting physician. VIII. "Artificial nutrition and hydration'' means invasive procedures such as but not limited to tn, only postpone the moment of death. VII. "Permanently unconscious'' means a lasting condition, indefinitely and without change, in which thought, awareness of self and environment, and all other indease, or illness which is such that death is imminent and the application of life-sustaining measures would, within the reasonable medical judgment of the attending physician and a consulting physiciaanently unconscious by 2 physicians who have personally examined the patient, one of whom shall be the attending physician. VI. "Terminal condition'' means an incurable condition caused by injury, disSA 329. V. "Qualified patient'' means a patient who has executed a declaration in accordance with this chapter and who has been diagnosed and certified in writing to be in a terminal condition or perm participate in the decision- making process. Living Will Information & Instructions ­ Page 2 IV. "Physician'' means a medical doctor licensed to practice in the state of New Hampshire pursuant to R-sustaining procedures be taken when the person executing said document is in a terminal condition or is permanently unconscious, without hope of recovery from such condition and is unable to activelyance of any medical procedure deemed necessary to provide comfort care or to alleviate pain. III. "Living will'' means a document which, when duly executed, contains the express direction that no life consulting physician, the patient is in a terminal condition or is permanently unconscious. "Lifesustaining procedures'' shall not include the administration of medication, sustenance, or the perform and a consulting physician, when applied to the qualified patient, would serve only to artificially postpone the moment of death, and where, in the written judgment of the attending physician and thes any medical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital function, which, in the written judgment of the attending physicianr: I. "Attending physician'' means the physician selected by or assigned to the patient who has primary responsibility for the treatment and care of the patient. II. "Life-sustaining procedures'' mean physician to provide, withhold, or withdraw life-sustaining procedures in the event such person is in a terminal condition or is permanently unconscious. Section 137-H:2 Definitions - In this chapteication between patients and their physicians, the legislature hereby declares that the laws of this state shall recognize the right of a competent person to make a written declaration instructing hisendering of his own medical care. In order that the rights of persons may be respected even after they are no longer able to participate actively in decisions about themselves, and to encourage communS) Section 137-H:1 Purpose and Policy. - The state of New Hampshire recognizes that a person has a right, founded in the autonomy and sanctity of the person, to control the decisions relating to the rthe New Hampshire Revised Statutes. For your convenience, we have included useful excerpts from the New Hampshire Statutes relating to Living Wills. TITLE X (PUBLIC HEALTH) CHAPTER 137-H (LIVING WILLage contains (1) Information and Instruction for New Hampshire Living Will; (2) New Hampshire Living Will. This New Hampshire Living Will is based on Title X Chapter 137-H Section 137-H:3 et. Seq. of ______________________________ ______________________________________ Notary Public/Justice of the Peace My Commission Expires: -5- Information and Instructions New Hampshire Living Will This packress: ______________________________________ -4- STATE OF NEW HAMPSHIRE COUNTY OF __________ The foregoing instrument was acknowledged before me this __________ day of __________, 20 ___, by ________________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Addprincipal has affirmed that he or she is aware of the nature of the document and is signing it freely and voluntarily. _____________________________________________ (Witness Signature) Print Name: ______________________________ (Signature) I declare that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for health care is signed and that the ____________________ ______________________________________________________________________________ In witness whereof, I have hereunto signed my name this __________ day of ___, 20___ ______________the following persons and institutions will have signed copies: _____________________________________________________________________________ __________________________________________________________ing the effect of this document. I have read and understand the information contained in the disclosure statement. The original of this document will be kept at __________________________________ and ereby appoint ____________________________________________ of ___________________________________ as alternate agent. I hereby acknowledge that I have been provided with a disclosure statement explain_________________________________ (attach additional pages as necessary) In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to act as my health care agent, I h___________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -3- ______________________________________________________________________________ ______________________________________________________________________________ ___ treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason. You may leave this question blank if you desire. _____________________________________________y include any specific desires or limitations you deem appropriate, such as when or what life-sustaining treatment you would want used or withheld, or instructions about refusing any specific types of nutrition and hydration continue to be given to me. (If you fail to complete item 3, your agent will not have the power to direct the withdrawal of artificial nutrition and hydration.) 4. Here you made it): _______ (a) artificial nutrition and hydration not to be started or, if started, be discontinued, -or________ (b) although all other forms of life-sustaining treatment be withdrawn, artificialon). In carrying out any instructions I have given above in #1 or #2 or any instructions I may write in #4 below, I authorize my agent to direct that (circle your choice of (a) or (b) and initial besiYES) _____________ (NO) ________________ 3. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding (artificial nutrition and hydrati___ 2. Whether terminally ill or not, if I become permanently unconscious I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your choice and initial beneath it.). (so suffering from a terminal illness, I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your choice and initial beneath it.). (YES) _____________ (NO) _____________isagreement with any of the following statements and give your agent power to act in those specific circumstances. 1. If I become permanently incompetent to make health care decisions, and if I am ald pressure, blood transfusions, and antibiotics.) There is also a section which allows you to set forth specific directions for these or other matters. If you wish you may indicate your agreement or dch as but not limited to the following: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the use of other external mechanical and technological devices, drugs to maintain bloosome general statements concerning the withholding or removal of life-sustaining treatment are set forth below. (Life-sustaining treatment is defined as procedures without which a person would die, su I become unable to make my own health care decisions. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. -2- For your convenience in expressing your wishes, any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. This durable power of attorney for health care shall take effect in the eventCARE PROVIDER OR ONE OF THEIR EMPLOYEES. POWER OF ATTORNEY I, ___________________________________, hereby appoint ___________________________ of ________________________________ as my agent to make SSES: --the person you have designated as your agent; --your spouse; --your lawful heirs or beneficiaries named in your will or a deed; ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL OT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNE unwilling, unable, unavailable, or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions for you. THIS POWER OF ATTORNEY WILL Ncument may not be changed or modified. If you want to make changes in the document you must make an entirely new one. You should consider designating an alternate agent in the event that your agent isnnot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This do decisions made in good faith on your behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment caagent and your physic ian and give each a signed copy. You should indicate on the document itself the people and institutions who will have signed copies. Your agent will not be liable for health carehe law does not permit a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; tou appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an -1- employee of a hometions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. The person ynd the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgable about these issues and can answer your quesou would have had if made consistent with state law. It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understant will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisions about your health care as y must say so. Otherwise, your agent will not be able to direct that. Under no conditions will your agent be able to direct the withholding of food and drink for you to eat and drink normally. Your ageach additional pages if you need more space to complete your statement. If you want to give your agent authority to withhold or withdraw the artificial providing of nutrition and fluids, your documentu must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person ineligible to be your agent. You may attou lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the certification that you lack capacity, yoou may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will begin when your doctor certifies that y treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication. Ying treatment. Your agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of thata broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaine of making them yourself. "Health care'' means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your agent, therefore, can have the power to make ANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you when you are no longer capablle Power Of Attorney For Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTarising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Durabould have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you shided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from V. A nonrelative of the principal who is an employee of the principal's residential care provider. [_] These forms are provided "as is" and no implied or express warranties have been made or are provng capacities: I. The principal's health care provider. II. A nonrelative of the principal who is an employee of the principal's health care provider. III. The principal's residential care provider. I care shall be in substantially the following form (see form below): 137-J:4 Restrictions on Who May Act as Agent. A person may not exercise the authority of agent while serving in one of the followi be in substantially the following form (see form below): 137-J:14 Durable Power of Attorney; Disclosure Statement The disclosure statement which must accompany a durable power of attorney for healthby the principal's name written by some other person in the principal's presence and at the principal's express direction. 137-J:15 Durable Power of Attorney; Form The durable power of attorney shallfirmed that he was aware of the nature of the document and signed it freely and voluntarily. If the principal is physically unable to sign, the durable power of attorney for health care may be signed loyee. The witness shall affirm that the principal appeared to be of sound mind and free from duress at the time the durable power of attorney for health care was -2- signed and that the principal afill, trust or other testamentary instrument or deed in existence or by operation of law. No more than one such witness may be the principal's health or residential care provider or such provider's empes, neither of whom shall, at the time of execution, be the agent, the principal's spouse or heir, or a person entitled to any part of the estate of the principal upon death of the principal under a wntial care provider of such revocation. 137-J:5 Execution and Witnesses The durable power of attorney for health care shall be signed by the principal in the presence of 2 or more subscribing witnessnotify the agent, the attending physician, and staff responsible for the principal's care of the revocation. An agent who becomes aware of such revocation shall inform the principal's health or resideresidential care provider who is informed of or provided with a revocation of a durable power of attorney for health care shall immediately record the revocation in the principal's medical record and able power of attorney for health care following filing for divorce shall make effective the designation of the former spouse as agent under the durable power of attorney. II. A principal's health or hen there is an alternate agent designated, in which case the designation of the spouse shall be revoked and the alternate designation shall become effective. Re-execution or re-affirmation of the dur the principal of a subsequent durable power of attorney for health care; or (c) By the filing of an action for divorce of the principal and spouse, where the spouse is the principal's agent, except w notification by the principal to the agent or to a health or residential care provider orally, or in writing, or by any other act evidencing a specific intent to revoke the power; (b) By execution byill be physically harmful to the patient or prolong severe pain which cannot be alleviated by medication. 137-J:6 Revocation. ­ I. A durable power of attorney for health care shall be revoked: (a) Byd an obstetrician who has examined the patient, such treatment or procedures will not maintain the patient in such a way as to permit the continuing development and live birth of the unborn child or w (c) To consent to withholding life-sustaining treatment from a pregnant patient, unless, to a reasonable degree of medical certainty, as certified on the patient's chart by the attending physician aneatment. V. Nothing in this chapter shall be construed to give an agent authority: -1- (a) To consent to voluntary admission to any state institution; (b) To consent to a voluntary sterilization; orcipal over the principal's objection. The principal's attending physician shall make reasonable efforts to inform the principal of any proposed treatment, or of any proposal to withdraw or withhold tre power of attorney for health care is in effect and irrespective of the principal's lack of capacity to make health care decisions at the time, treatment may not be given to or withheld from the prinace, as to the lack of decisional capacity of the principal. The person so designated by the principal shall not be the agent, or a person ineligible to be the agent. IV. Notwithstanding that a durablrable power of attorney for health care, a person designated by the principal in the durable power of attorney for health care may certify in writing, acknowledged before a notary or justice of the perecord. A durable power of attorney for health care may include a provision that, if the principal has no attending physician for reasons based on his religious or moral beliefs as specified in the du by the principal's attending physician and filed in the principal's medical record. When and if a person regains capacity to make such decisions, such event shall be noted in the principal's medical practice. III. Under a durable power of attorney for health care, the agent's authority shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing pursuant to the provisions of RSA 137-H; or if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's best interests and in accordance with accepted medical d religious or moral beliefs, as stated orally or otherwise communicated by principal to agent, or as contained in the durable power of attorney for health care or in a terminal care document executede. II. After consultation with the attending physician and other health care providers, the agent shall make health care decisions in accordance with the agent's knowledge of the principal's wishes anh by the principal in the durable power of attorney for health care, the agent shall have the authority to make any and all health care decisions on the principal's behalf that the principal could maktatutes relating to the New Hampshire Power of Attorney for Health Care Form. 137-J:2 Scope and Duration of Authority. I. Subject to the provisions of this chapter and any express limitations set fortis New Hampshire Power of Attorney for Health Care is based on Title X Chapter 137-J Section 137-J:15 et. Seq. of the New Hampshire Statutes. The following are useful excerpts from the New Hampshire Sower of Attorney for Health Care This package contains (1) Information and Instruction for New Hampshire Power of Attorney for Health Care; (2) New Hampshire Power of Attorney for Health Care Form. Thd be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions New Hampshire Pe sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shouland/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to makranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warNew Hampshire Advance Health Care Directive This package contains both a New Hampshire Power of Attorney for Health Care and a New Hampshire Living Will. Together these forms are also sometimes known New Hampshire