HEALTHCARE DECLARATION

I, [declarant_name], residing at [declarant_address], being of sound mind and memory, willfully and voluntarily execute this document, directing my healthcare treatment preferences under the laws of the State of New Hampshire. This directive shall become effective only if I become incapacitated and am unable to make or communicate my own healthcare decisions.

HEALTHCARE proxy

DESIGNATION OF HEALTH CARE PROXY: I hereby appoint [agent_name], residing at [agent_address] (Phone: [agent_phone]), as my primary Health Care Agent to make all medical decisions on my behalf if I am unable to make them myself. My agent shall have full authority to request, receive, review, and consent to or refuse any medical treatment, consistent with the wishes expressed in this directive.

ALTERNATE HEALTH CARE AGENT: If my primary agent is unable, unwilling, or ineligible to serve, I appoint [alternate_agent_name], residing at [alternate_agent_address] (Phone: [alternate_agent_phone]), as my alternate Health Care Agent.

END-OF-LIFE DIRECTIVES

LIFE-SUSTAINING TREATMENT DIRECTIVE: If I am diagnosed by physicians as being in a terminal condition, a persistent vegetative state, or permanently unconscious, and my doctors determine that there is no reasonable medical expectation of my recovery, I direct that all life-sustaining treatments (including ventilators, cardiopulmonary resuscitation (CPR), and kidney dialysis) be withheld or withdrawn. I wish to be permitted to die naturally, receiving only comfort care and pain management to alleviate suffering.

ARTIFICIAL NUTRITION AND HYDRATION: I direct that artificial nutrition (tube feeding) and hydration (intravenous fluids) be withheld or withdrawn if I am in a terminal state or permanently comatose, as I do not wish to artificially prolong the process of dying.

ORGAN & TISSUE DONATION

ORGAN DONATION: Upon my death, I consent to the donation of any needed organs, tissues, or body parts for transplantation, therapy, medical research, or educational purposes.

EXECUTION

IN WITNESS WHEREOF, I have executed this Advance Healthcare Directive and Living Will on this ___ day of ________, 20__.

WITNESS ATTESTATION

We declare that the Declarant signed this directive in our presence and that the Declarant appeared to be of sound mind and free of duress. We certify that we are not the designated healthcare agent, healthcare providers, or employees of the healthcare facility treating the Declarant.

NOTARY ACKNOWLEDGMENT

STATE OF NEW HAMPSHIRE, COUNTY OF ____________________. Subscribed, sworn to, and acknowledged before me by the Declarant on this ___ day of ________, 20__.