CBST Collection of Wishes for Advance Healthcare & End of Life Planning

CBST clergy and staff want to support you in times of need. To better enable us to do so, please complete the following questions to best of your ability.

CBST is NOT seeking copies of any documentation. These questions are intended to help you sort out and determine your wishes and instructions for friends, family, and CBST clergy.

This list of questions, and your answers, is a guide, not a legal document. When completing the actual legal document, be it a last will and testament, living will, health care proxy, or any other document, it is highly recommended that you obtain counsel from appropriate legal, medical or financial professionals to ensure that the documents are accurately and completely executed.

If you could use guidance, contact CBST Social Worker Judy Ribnick, jribnick@cbst.org, and put "Collection" in the subject line of your email.

Your Information

First Name

Last Name

If you have a Hebrew or Yiddish name, please share here:

English name(s) of your parent(s)

This helps CBST create your Hebrew name if you do not know or have one.

Hebrew name(s) of your parent(s):

Healthcare Proxy

Do you have a health care proxy?

A health care proxy form is a type of advance care directive that allows you to designate someone (an "agent") to make health care decisions for you if you cannot make such decisions for yourself. CBST encourages all adults 18 years and over to complete this legally recognized form.

If you DO NOT have a health care proxy document, would you like a trained CBST volunteer to help you through this process? This is offered free to members.

Healthcare Agent First Name

Agent Last Name

Agent Phone

Agent Email

Agent Pronouns

Your Relationship to Agent

Healthcare & End-of-Life Coordinator

Do you have a healthcare/end-of-life coordinator?

This person would coordinate your healthcare/end-of-life details with CBST.

Is your healthcare/end-of-life coordinator the same person as your healthcare agent?

Healthcare/End of Life Coordinator Details

Coordinator First Name

Coordinator Last Name

Coordinator Phone

Coordinator Email

Coordinator Pronouns

Your Relationship to Coordinator

Living Will

Do you have a Living Will?

A living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, such as pain management or organ donation. (If you do not have one and want guidance, feel free to contact CBST Social Worker Judy Ribnick, jribnick@cbst.org, 917-310-4656)

Will & Lawyer

Do you have a will?

Do you have a lawyer?

Funeral Home

Do you have pre-arrangements with a funeral home?

Please share the name, address, and office phone here:

Cemetery Information

Do you have a cemetery plot?

If you do not have a cemetery plot, are you interested in learning about CBST's cemetery, a private section in Cedar Park Cemetery, Paramus, NJ?

Please include the location and details here (such as block/plot/row numbers, etc.). Please also include the office phone number for the cemetery and, if in a family plot, the name and contact information of the person who holds the certificate.

Funeral Wishes

Do you have wishes for your funeral? What type of service would you want? (For example, specify here more or less traditional, favorite songs you would like sung, poems you would like read, etc.) We will do our best to honor these requests.

Is there anyone in the CBST community you would like us to be in contact with?

Is there anything else that you want CBST to know about your healthcare/end-of-life wishes?

Contact Information