Husband's Full Name

Option 1

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Wife's Full Name

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Home Mailing Address

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List of your children

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If your spouse is living at the time of your death, would your entire estate pass to your surviving spouse?

Yes, my entire estate will convey to my spouse
No, only a portion of my estate will convey to my spouse

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If you and your spouse die at the same time, or your spouse dies before you, who will receive your estate?

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If you have minor children, and you pass while they are still under the age of 18, who would you desire to be their legal guardian?

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If you answered the previous question, what is the address and telephone number of the person or persons you would propose as legal guardians/s of your minor child/ren?

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If your spouse is alive at the time of your death, would you want them to serve as the Personal Representative / Executor of your Estate?

Yes, I would want my spouse to serve
No, I would want someone else to serve as Personal Representative / Executor of my estate

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Who is your first choice to serve as the Personal Representative / Executor of your Estate?

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Who is your second choice to serve as the Personal Representative / Executor of your Estate?

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Who is your third choice to serve as the Personal Representative / Executor of your Estate?

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If one the people who would receive a share of your Estate died before you, would you want the person's share to pass to their children?

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If you were still living, but unable to handle your own financial affairs, who would you want to act as your Power of Attorney?

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If you were unable to communicate or lacked ability to answer questions, who would your first choice be to make medical decisions for you?

Name, address, and best telephone numbers

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If you were unable to communicate or lacked ability to answer questions, who would your second choice be to make medical decisions for you?

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If you were unable to communicate or lacked ability to answer questions, who would your third choice be to make medical decisions for you?

Name, address, and best telephone numbers

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Do you consider yourself and organ donor?

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If you were unconscious, or unable to communicate, for whatever reason, with respect to any Life-Sustaining Treatment, which of the following statements do you think best describes your wishes?

I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning the life-sustaining treatment.
I do not want my life to be prolonged and I do not want life-sustaining treatment: (a) if I have a condition that is incurable or irreversible and, without the administration of life-sustaining procedures, expected to result in death within a relatively short period of time; or (b) if I am in a state of permanent unconsciousness.
I want my life to be prolonged to the greatest extent possible, within the standards of accepted medical practice, without regard to my condition, the chances I have for recover, or the cost of the procedures.
None of the above. See my own answer below

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If none of the above apply, describe in your own words your desire:

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With respect to Nutrition and Hydration provided by means of a nasogastric tube or tube into the stomach, intestines, or veins:

I do not want to receive these forms of artificial nutrition and hydration, and they may be withheld or withdrawn under the conditions given above.
I do want to receive these forms of artificial nutrition and hydration.
I do want to receive hydration, but I do not want to receive artificial nutrition, and artificial nutrition may be withheld or withdrawn under the conditions given above.
None of the above. See my own answer below.

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If none of the above apply, describe in your own words your desire:

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If a child or young person were to receive a portion of your Estate, how old would you want them to be before they could have free access to their share?

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If they would not have access at age 18, would you want them to have limited access for college tuition and expenses?

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Biering Law Firm, P.C. : Basic Will and Estate Planning