STATE OF NEW YORK
DURABLE POWER OF ATTORNEY FOR MEDICAL TREATMENT
I, , having an address at , appoint having an address at as my attorney-
in-fact to carry out my specific and general instructions and wishes with respect to and all
In the event the person I appoint is unable, unwilling or unavailable to act as my health care
agent, I hereby appoint having an address at
I have made known to my attorney-in-fact and authorize him/her to express and carry out my
specific and general instructions and wishes with respect to medical treatment, including my
desires on the subject of withholding or withdrawing all forms of life-sustaining medical
treatment, including tubal feedings and medication.
This power of attorney shall become effective when I can no longer make my own medical
decisions and shall not be affected by subsequent disability or incompetence. The determination
of whether I can make my own medical decisions is to be made by my attorney-in-fact, or if he
or she is unable, unwilling or unavailable to act, by my alternate attorney-in-fact.
IN WITNESS WHEREOF, I have set my hand this day of , 20 .
The above principal, who appears to be of sound mind and under no duress, voluntarily signed
this instrument in our presence. I am not the person appointed as attorney-in-fact or alternate
attorney-in-fact by this document.