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