Revocation of Durable Health Care Power of Attorney


I, * (printed name),  
 of (address) * 
 do revoke the Durable Health Care Power of Attorney dated *  , 20*  ,
 which was granted to *  (printed name),         of  (address) *  , to    
 act as my attorney in fact for health care decisions and I revoke any appointment of the above
 person as my health care agent, health care representative, or health care proxy.

Dated * , 20 * 


*
Signature of person revoking power of attorney
*
Printed name of person revoking power of attorney