Revocation of Advance Health Care Directive 



 I, * , am the maker and signatory of an Advance Health Care Directive which was dated *  , and
which was executed by me for use in the State of * .

By this written revocation, I hereby entirely revoke such Advance Health Care Directive, any Living
Will, any Durable Power of Attorney for Health Care, any Organ Donation, or any other appointment
or designation of a person to make any health care decisions on my behalf. I intend that all of the
above mentioned documents have no force or effect whatsoever.

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF
THIS DOCUMENT.

 Signature *           Date *