No organ, eye or tissue donation
Signed refusal · N.Y. Pub. Health Law §§ 4301, 4305
No family member, surrogate, agent, hospital administrator, or other person may authorize an anatomical gift on my behalf.
New York · 2 documents
Refusal of Specific Interventions and Health Data
Confirm this is your patient
Margaret Ellison Hale
- Born
- 1954
- Record
- K7PF-2QX9
No routine vaccines or immunizations
Prophylaxis after a suspected exposure is accepted. Tetanus, rabies and hepatitis B prophylaxis may be given.
This is not a DNR.
Full treatment and resuscitation accepted.
Signed instrument
Executed14 MAR 2026
State of executionNew York
18 AUG2026
Confirmed in forceThis refusal remains in effect until revoked in the manner provided by statute. 3 dated confirmations on record.
Healthcare agent
Daniel Hale — son
Call (212) 555-0142Emergency health information
Severe penicillin allergy. On anticoagulants.
Allergies
- PenicillinAnaphylaxis, 2011
- Latex
Conditions
- Atrial fibrillation
- Type 2 diabetesInsulin dependent
Medications
- Warfarin5mg daily, evening
- Metformin1000mg twice daily
Implanted devices
- PacemakerImplanted 2021. MRI conditional.
Care instructions
Rescue inhaler in handbag. Difficult intubation noted 2019.
Updated 19 JUL 2026