New Hampshire Living Will Template
This Living Will is designed to express your preferences regarding medical treatment in the event that you become unable to communicate your wishes. It complies with the New Hampshire statutes governing advance directives.
Individual Information
- Name: ____________________________
- Date of Birth: ______________________
- Address: ___________________________
- City, State, Zip Code: ______________
Declaration
I, the undersigned, being of sound mind, willfully and voluntarily declare this to be my Living Will. In the event that I am diagnosed with a terminal condition, I wish to provide the following instructions:
- I do not want life-sustaining treatment if I am unable to make my own healthcare decisions.
- I direct that any necessary pain management be provided, even if it may hasten my death.
- I wish to be treated with dignity and in alignment with my wishes concerning end-of-life care.
Healthcare Agent Designation
If I am unable to communicate my healthcare decisions, I appoint the following individual as my healthcare agent:
- Name: ____________________________
- Phone Number: ____________________
- Address: ___________________________
Witnesses
This Living Will must be signed in the presence of two witnesses who are at least 18 years old and are not related to me by blood or marriage. By signing below, the witnesses confirm that I appeared to be of sound mind:
- Witness 1 Name: ____________________________
- Witness 1 Signature: _________________________
- Date: ____________
- Witness 2 Name: ____________________________
- Witness 2 Signature: _________________________
- Date: ____________
Signature
I hereby declare that I am the individual named above, and I understand the contents of this Living Will. My signature below indicates my intent to create this document.
Signature: ____________________________
Date: ____________