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    -- Halachic Living Will (general form)

PROXY AND DIRECTIVE WITH RESPECT TO
HEALTH CARE DECISIONS AND POST-MORTEM DECISIONS

I, _____________________________, hereby declare as follows:

1. Appointment of Agent: In recognition of the fact that there may come a time when I will become unable to make my own health care decisions because of illness, injury or other circumstances, I hereby appoint

Name of Agent: ___________________________________

Address: _________________________________________

	 _________________________________________

Telephone: Day _________________ Evening _________
as my health care agent to make any and all health care decisions for me, consistent with my wishes as set forth in this directive.

If the person named above is unable, unwilling or unavailable to act as my agent, I hereby appoint

Name of Alternate Agent: _________________________

Address: _________________________________________

	 _________________________________________

Telephone: Day _________________ Evening _________
to serve in such capacity.

This appointment shall take effect in the event I become unable, because of illness, injury or other circumstances, to make my own health care decisions.

2. Jewish Law to Govern Health Care Decisions: I am Jewish. It is my desire, and I hereby direct, that all health care decisions made for me be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. By way of example, and without limiting in any way the generality of the foregoing, it is my wish that Jewish law and custom should dictate the course of my health care with respect to such matters as the performance or non-performance of cardio-pulmonary resuscitation if I suffer cardiac or respiratory arrest; the initiation or discontinuance of any particular course of medical treatment or other form of life-support maintenance, including tube-delivered nutrition and hydration; and the method and timing of determination of death.

3. Ascertaining the Requirements of Jewish Law: In order to effectuate my wishes, if any question arises as to the requirements of Jewish law and custom in connection with this declaration, I direct my agent to consult with and follow the guidance of the following Orthodox Rabbi:

Name of Rabbi: ___________________________________

Address:   _______________________________________

	   _______________________________________

Telephone:  Day ________________ Evening _________
If such rabbi is unable, unwilling or unavailable to provide such consultation and guidance, then I direct my agent to consult with and follow the guidance of an Orthodox Rabbi referred by the following Orthodox Jewish institution or organization:

Name of Institution/Organization: ________________

__________________________________________________

Address: _________________________________________

	 _________________________________________

Telephone:  Day _________________ Evening ________
If such institution or organization is unable, unwilling or unavailable to make such a reference, or if the rabbi referred by such institution or organization is unable, unwilling or unavailable to provide such guidance, then I direct my agent to consult with and follow the guidance of an Orthodox Rabbi whose guidance on issues of Jewish law and custom my agent in good faith believes I would respect and follow.

4. Direction to Health Care Providers: Any health care provider shall rely upon and carry out the decisions of my agent, and may assume that such decisions reflect my wishes and were arrived at in accordance with the procedures set forth in this directive, unless such health care provider shall have good cause to believe that my agent has not acted in good faith in accordance with my wishes as expressed in this directive.

If the persons designated in paragraph 1 above as my agent and alternate agent are unable, unwilling or unavailable to serve in such capacity, it is my desire, and I hereby direct, that any health care provider or other person who will be making health care decisions on my behalf follow the procedures outlined in paragraph 3 above if any questions of Jewish law and custom should arise.

Pending contact with the agent and/or rabbi described above, it is my desire, and I hereby direct, that all health care providers undertake all essential emergency and/or life sustaining measures on my behalf.

5. Post-Mortem Decisions: It is also my desire, and I hereby direct, that after my death, all decisions concerning the handling and disposition of my body be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. By way of example, and without limiting in any way the generality of the foregoing, it is my wish that there be conformance with Jewish law and custom with respect to such matters and questions as whether there exist exceptional circumstances that would permit an exception to the general prohibition under Jewish law against the performance of an autopsy or dissection of my body; the permissibility or non-permissibility of the removal and usage of any of my body organs or tissue for transplantation purposes; and the expeditious burial of my body and all preparations leading to burial.

Time is of the essence with regard to these questions. I therefore direct that any health care provider in attendance at my death notify the agent and/or rabbi described above immediately upon my death, in addition to any other person whose consent by law must be solicited and obtained prior to the use of any part of my body as an anatomical gift, so that appropriate decisions and arrangements can be made in accordance with my wishes. Pending such notification, it is my desire, and I hereby direct, that no autopsy, dissection or other post-mortem procedure be performed on my body.

6. Incontrovertible Evidence of My Wishes: If, for any reason, this document is deemed not legally effective as a health care proxy, or if the persons designated in paragraph 1 above as my agent and alternate agent are unable, unwilling or unavailable to serve in such capacity, I declare to my family, my doctor and anyone else whom it may concern that the wishes I have expressed herein with regard to compliance with Jewish law and custom should be treated as incontrovertible evidence of my intent and desire with respect to all health care measures and post-mortem procedures; and that it is my wish that the procedure outlined in paragraph 3 above should be followed if any questions of Jewish law and custom should arise.

7. Duration and Revocation: It is my understanding and intention that unless I revoke this proxy and directive, it will remain in effect indefinitely. My signature on this document shall be deemed to constitute a revocation of any prior health care proxy, directive or other similar document I may have executed prior to today's date.

Date:  _______________________________


_______________________       Residing at ________
[Your signature; or, if
you are not physically        ____________________
capable of signing, the       [address]
signature ofanother person
signing your name on
your behalf]

DECLARATION OF WITNESSES

I declare that the person who signed (or asked another to sign) this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He (or she) signed (or asked another to sign for him or her) this document in my presence (and that person signed in my presence). I am not the person appointed as agent by this document.

______________________  Residing at ______________
Witness

                        __________________________
	                [address]


______________________  Residing at ______________
Witness

                        __________________________
	                [address]

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