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: