Revocation Of Living Will

This document ends the legal effect of a previously enacted living will.

STATE OF The State In Which Signed

COUNTY OF The County In Which Signed

WHEREAS, on Month, Day Last Known Living Will Signed, Year Last Known Living Will Signed, I, Name of the Person Revoking, 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.


Declarant: Name of Person Revoking

Address: Street Address of the Signer

City, State of the Signer

Social Security Number: Social Security Number of Signer

I/We, the undersigned witnessed the Declarant sign this instrument and believe him or her to be of sound mind.

Witness: Name of Witness One

Address: Street Address of Witness One

City, State of Witness One

Witness: Name of Witness Two

Address: Street Address of Witness Two

City, State of Witness Two

STATE OF State In Which Signed

COUNTY OF County In Which Signed

Before me, the undersigned Notary Public personally appeared

Name of the Person Revoking, and the witnesses above, who all acknowledged

that they executed this instrument freely and willingly for the

purposes therein stated.

Notary Public: Name of Notary Public

My commission expires: Date on Which Commission of Notary Public Expires

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