$13.95

Add to cart

New Hampshire ature________________________________________ Official Capacity _________________________________ 2 orn to and signed before me by _________________________________________, declarant ___________________________________, and ___________________________________, witnesses on ____________________ Signofficial authorized to administer 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: Sw_____________________________ (Witness Signature) _____________________________________________ (Witness Signature) The affidavit shall be made before a notary public or justice of the peace or other other witness. 3. To the best 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. ________________ a free and voluntary act for 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__________ We, the following witnesses, 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 aslaration. __________________________________________ (Declarant's Signature) Print Name: ________________________________ Address: ___________________________________ _________________________________ to refuse medical or surgical treatment 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 decility to give directions regarding 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______________________ ____________________________________________________________________________ ____________________________________________________________________________ In the absence of my abt. If you do not choose "yes,'' artificial nutrition and hydration will be provided and will not be removed.) Additional Instructions (optional): ______________________________________________________ave given under this section, I authorize that artificial nutrition and hydration not be started or, if started, be discontinued. (Yes) _______ (No) ______ (Circle your choice and initial beneath iide me with comfort care. I realize 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 hocedures be withheld or withdrawn, 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 provd or that I will remain in a permanently unconscious condition and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such prysicians who have personally examined 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 utilizecumstances set forth below, do hereby 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 ph ___ day of ___ (month, year). I, _________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the cir 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 Living Will DECLARATION Declaration made this 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 shouldnd/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 makeas to their suitability for any specific purpose or as to their legal effect or completeness. Information & Instructions ­ Page 3 [_]These forms are not intended and are not a substitute for legal aospital, no more than one witness may be the health 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 inst the estate of the person, and shall be acknowledged 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 hn's spouse, heir at law, attending physician or 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 aga7-H:4 Execution and Witness. ­ The document set 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 persofective if the person is permanently incapable of 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 13commonly known as a living will, directing that no lifesustaining procedures be used to prolong his life when he is in a terminal condition or is permanently unconscious. The document shall only be efenance'' means the natural ingestion of food or fluids 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 invasive procedures such as but not limited to the following: nasogastric tubes; gastrostomy tubes; intravenous feeding or hydration; and hyperalimentation. It shall not include sustenance. IX. "Sustreness of self and environment, and all other indicia of consciousness are absent as determined by the attending physician and a consulting physician. VIII. "Artificial nutrition and hydration'' meansthe attending physician and a consulting physician, only postpone the moment of death. VII. "Permanently unconscious'' means a lasting condition, indefinitely and without change, in which thought, awaeans an incurable condition caused by injury, disease, or illness which is such that death is imminent and the application of life-sustaining measures would, within the reasonable medical judgment of in writing to be in a terminal condition or permanently unconscious by 2 physicians who have personally examined the patient, one of whom shall be the attending physician. VI. "Terminal condition'' mctice in the state of New Hampshire pursuant to RSA 329. V. "Qualified patient'' means a patient who has executed a declaration in accordance with this chapter and who has been diagnosed and certifiedhope of recovery from such condition and is unable to actively participate in the decision-making process. Information & Instructions ­ Page 2 IV. "Physician'' means a medical doctor licensed to prahen duly executed, contains the express direction that no life-sustaining procedures be taken when the person executing said document is in a terminal condition or is permanently unconscious, without e the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide comfort care or to alleviate pain. III. "Living will'' means a document which, wre, in the written judgment of the attending physician and the consulting physician, the patient is in a terminal condition or is permanently unconscious. "Lifesustaining procedures'' shall not includion, which, in the written judgment of the attending physician and a consulting physician, when applied to the qualified patient, would serve only to artificially postpone the moment of death, and whend care of the patient. II. "Life-sustaining procedures'' means any medical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital functntly unconscious. Section 137-H:2 Definitions - In this chapter: I. "Attending physician'' means the physician selected by or assigned to the patient who has primary responsibility for the treatment a competent person to make a written declaration instructing his physician to provide, withhold, or withdraw life-sustaining procedures in the event such person is in a terminal condition or is permaneactively in decisions about themselves, and to encourage communication between patients and their physicians, the legislature hereby declares that the laws of this state shall recognize the right of actity of the person, to control the decisions relating to the rendering of his own medical care. In order that the rights of persons may be respected even after they are no longer able to participate iving Wills. TITLE X (PUBLIC HEALTH) CHAPTER 137-H (LIVING WILLS) Section 137-H:1 Purpose and Policy. - The state of New Hampshire recognizes that a person has a right, founded in the autonomy and sanl is based on Title X Chapter 137-H Section 137-H:3 et. Seq. of the New Hampshire Revised Statutes. For your convenience, we have included useful excerpts from the New Hampshire Statutes relating to LInformation and Instructions New Hampshire Living Will This package contains (1) Information and Instruction for New Hampshire Living Will; (2) New Hampshire Living Will. This New Hampshire Living Wil New Hampshire