This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This is a required section which provides an opportunity for the Declarant to request that the provisions of this document be honored. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
This is a required section in which a public official (such as a Notary Public) acknowledges the signatures of the Declarant and the witnesses. Press [Ctrl+F1] for more information.
Times New Roman
Living Will
LIW_NH
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WNH01
! Declaration Section (1 of 10)
DECLARATION
Declaration made this _____ day of _______________, 19___.
I, !, 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, and do hereby declare:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WNH02
! Life Support Section (2 of 10)
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition
! [Optional COMA provision] or a permanently unconscious condition
by 2 physicians 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 utilized,
! [included if COMA checkbox is marked] 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 procedures 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 provide me with comfort care.
This required section describes the circumstances under which you, the Declarant, want to have life-sustaining procedures or treatment withheld or withdrawn if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WNH03
! Optional Nutrition Section (3 of 10)
[Initial the choice that you select] 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 have given under this section, I authorize that artificial nutrition and hydration
! _____ (initials) BE STARTED, or if started, BE CONTINUED.
! _____ (initials) NOT BE STARTED, or if started, BE DISCONTINUED.
Enter an X to include a paragraph that states whether you wish to receive or not to receive artificial nutrition and hydration if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X to authorize that artificially administered nutrition and hydration be STARTED, or if already in use, be CONTINUED, even though your physicians certify that you have a terminal or permanently unconscious condition.
Enter an X to authorize that artificially administered nutrition and hydration NOT BE STARTED, or if already in use, be DISCONTINUED, even though your physicians certify that you have a terminal or permanently unconscious condition.
LAL04
! Optional Pregnancy Section (4 of 10)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (5 of 10)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
LAL06
! Optional Severability Section (6 of 10)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WNH07
! Right of Refusal Section (7 of 10)
In the absence of my ability 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 to refuse medical or surgical treatment and accept the consequences of such refusal.
This required section states the Declarant's request that the Living Will be followed. It also notes the Declarant's basic right to make medical decisions, including the right to refuse treatment.
WNH08
! Declarant Signature Section (8 of 10)
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WNH09
! Witness Signature Section (9 of 10)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
State of New Hampshire
_________________________ County
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 as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him or her.
2. Each witness signed at the request of the Declarant, in his or her presence, and in the presence of the 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.
4. Neither of the undersigned witnesses is (i) the Declarant's spouse, or (ii) the Declarant's attending physician, or person acting under the direction or control of the attending physician or any other person who has a claim against the Declarant's estate.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses. The county in which the document was signed should be entered on the blank line at the time the document is signed.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WNH10
! Acknowledgement Section (10 of 10)
[This is a required section in which a Notary Public acknowledges that the Declarant and Witnesses signed the document.]
Sworn to and signed before me by !, Declarant, ! and !, witnesses.
_______________________________________
Signature
_______________________________________
Official Capacity
(Notary Public or other official
authorized to administer oaths)
This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document. Press [Ctrl+F1] for more information.