REVOCATION OF LIVING WILL

STATE OF ________)

COUNTY OF _______)

WHEREAS, on ______________, I, ____________, 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.

At this time, and after mature reflection, I have determined that

I do not desire for this instrument to have further effect, and I

therefore revoke the same.

Dated: __________________________________

________________________________________________

Declarant: __________________

Address: ____________________

____________________

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 _____________

COUNTY OF ____________

Before me, the undersigned Notary Public personally appeared

____________, 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: