Witness Affidavit of Oral Revocation of Advance Health Care Directive 


The following person, * , herein referred to as the declarant, was the maker and signatory of an
Advance Health Care Directive which was dated * , and which was executed by him or her for use
in the State of * . 

By this written affidavit, I, *  , the witness, hereby affirm that on the date of *  , I personally
witnessed the above-named  declarant make known to me, through verbal and/or non-verbal
methods, their clear and unmistakable intent to 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 his or her behalf. It is
my belief that the above-named declarant fully intended that all of the above-mentioned documents
no longer have any force or effect whatsoever.

Witness Acknowledgment

The declarant is personally known to me and I believe him or her to be of sound mind and under no
duress, fraud, or undue influence.

Witness Signature *  
Date *

Printed Name of Witness *