Revocation of Life Sustaining Agreement

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Revocation of Previous Living Will and Medical Care Restrictions

I, ________________, desire to make aware that after mature reflection, and, being aware of the right under the law to decline life- sustaining treatment, that I wish, should I ever be unable to make decisions for myself concerning my medical treatment that I receive life sustaining treatment even after a terminal diagnosis, even if the life prolonging treatment will delay the natural process of dying.

I have previously made a “living will” or other document expressing a desire contrary to that specified herein, and by this document I herewith revoke the same.

Dated: _________________________________________

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Declarant

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Witness & Address

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Witness & Address

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Witness & Address

City of residence: _______________

County of residence: _____________

State of residence: ______________

Social Security Number: __________

Date: _________________

________________________________________________________________

Witness

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Witness

STATE OF ________________________

COUNTY OF _______________________

This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of ________________, the Declarant, signed, sealed and published and declared the same as and for his declaration, in the presence of both these affiants; and that these affiants, at the request of said Declarant, in the presence of each other, and in the presence of said Declarant, all present at the same time, signed their names as attesting witnesses to said declaration.

Affiants further say that this affidavit is made at the request of ________________, Declarant, and in his presence, and that ________________ at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.

Taken, subscribed and sworn to before me by _________________ (witness) and ____________________________ (witness) this _______ day of ____________________________, 20_____.

My commission expires: __________________