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Living Will (click here for information)

(1.) Personal Information

Your Name: Select One Male Female
Spouse/Significant Other:Select One Male Female

Address:
County:

Telephone (Home):
Telephone (Office):
FAX Number:
EMAIL:

Health Care Representative

Name of Your Health Care Rep(s): Rel.
Addr:

Your Alternate Health Care Rep(s): Rel.
Addr:

Name of Spouse's Health Care Rep(s): Rel.
Addr:

Spouse's Alternate Health Care Rep(s): Rel.
Addr:

How To Order Those Documents!

The fee for the Living Will is as follows. Please select one:

$45.00- Living Wills for husband and wife

$25.00- Living Will for One

Please select the manner in which you wish to make payment. Select one:

I will mail my check to you (documents will be provided immediately upon receipt of payment)

I will pay by charge card and will call you with my charge account number.

Please indicate below the manner in which you wish to receive your documents:

Mail to my address written above

E-Mail my documents to me

FAX my documents to me

If you choose E-mail, please select your word processor format from the following list:

Should you have any questions completing the form or desire revisions to the draft submitted to you, please call me or email me to discuss your will.

Submit your worksheet, press this button

To clear this form and start over, press this button:

E-mail

William.jaekel@verizon.net

( http://members.verizon.net/~vze29fmr/index.html)

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Living Wills

Return to Form (living will)

A living will is a document in which you give instructions to your physician and family as to what, if any, life sustaining treatment (eg. experimental surgery, life support systems, drugs, artificial fluids and nutrition) you wish in the event that you are terminally ill or at the last stages of an illness. The living will is only used if you are unable to make theses decisions because you are in a coma or suffer from some other impairment.

In order to carry out your wishes under the living will, you appoint what is known as a health care representative. This appointment is similar to a limited medical power of attorney. You grant your health care representative the power to make medical decisions in the event that you are unable.

New Jersey by statute has adopted a form of living will. The form has three parts. In the first part you initial next to several choices or situations in which you may or may not want what is known as "life sustainining treatment". Life sustaining treatment is anything, be it surgery, drugs, etc., which will make you live longer. Secondly, you can appoint one or more health care representatives. Thirdly, there is a section to elect to make an organ donation. The form supplied with your package is the New Jersey statutory form.