SAMPLE REVOCATION OF LIVING WILL
STATE OF [list state signed]
COUNTY OF [list country where signed]
WHEREAS, on [list month and date of last living
will], [list year of living will],
I, [list name], executed a "living will" (or a
similar document styled as a "declaration" or "directive to physicians") which
provided that upon a terminal diagnosis, and my inability to communicate
decisions regarding the course of my treatment to my physicians, that no
extraordinary means be used to simply prolong my life.
This living will no longer reflects my desires should the circumstances
invoking such an instrument occur. I hereby revoke the said living will.
Dated: __________________________________
________________________________________________
Declarant: [list name]
Address: [list street address of signer]
[list city, state of signer]
Social Security Number: [list social security number]I/We,
the undersigned witnessed the Declarant sign this instrument and believe him or
her to be of sound mind.
________________________________________________
Witness:
Address:
________________________________________________
Witness:
Address:
STATE OF [list state signed]
COUNTY OF [list country where signed]
Before me, the undersigned Notary Public personally appeared
[list name], and the witnesses above, who all acknowledged
that they executed this instrument freely and willingly for the
purposes therein stated.
________________________________________________
Notary Public
My commission expires:
