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«INSTRUCTIONS (a) Please print your name on the first line of the form. (b) In section 1, print the name, address, and day, evening and cell/pager ...»

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Incontrovertible Evidence of My Wishes: If, for any reason, this document is deemed not legally effective as a health care declaration or proxy, or if the persons designated in section 1 above as my surrogate and alternate surrogate 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 section 3 above should be followed in determining the requirements of Jewish law and custom.

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The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

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