NEW HAMPSHIRE ADVANCE DIRECTIVE
NOTE: This form has two sections: the Durable Power of Attorney for Health Care and the
Living Will. You may complete both sections, or only one section.
SECTION I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I, _______________________________, (__________), hereby appoint ______________________________
(Date of Birth)
(Name of Health Care Agent)
(Health Care Agent’s address and phone #)
If you choose more than one agent, they will have authority in priority of the order their
names are listed, unless you indicate another form of decision making.) as my agent to
make any and all health care decisions for me, except to the extent I state otherwise in this
directive or as prohibited by law. This Durable Power of Attorney for Health Care shall take
effect in the event I lack the capacity to make my own health care decisions.
In the event the person I a