Connecticut Advance Directive

Information you will need

• Principal Name
• Health Representative Name
• Alternative Health Representative Name
• Witnesses Only: County
• Witnesses Only: Town
• Notary Only: Witness Name
• Notary Only: Month
• Notary Only: Year
• Notary Only: Commission Expiration
• Witness (2) City, State, and ZIP Code
• Witness (1) City, State, and ZIP Code
• Witness (1) Street Address
• Witness (2) Street Address
• Witnesses Only: Month
• Witnesses Only: Year
• Witness (3) Street Address
• Witness (3) City, State, and ZIP Code
• Witness (4) Street Address
• Witness (4) City, State, and ZIP Code
• Principal Signature Year
• No Health Care Representative
• No Health Care Instructions
• No Anatomical Gift
• Provide CPR

…and 20 more fields in the PDF.

The form includes 2 signature lines, a notary acknowledgment, a witness section.