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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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85 lines
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: