Revocation of Advance
Health Care Directive
Power of Attorney
ocstoc Legal Agreements
This document is intended to be used by a person to revoke his earlier
executed Advance Health Care Power Of Attorney.
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Attorney Drafted
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REVOCATION OF ADVANCE HEALTH CARE DIRECTIVE
POWER OF ATTORNEY
I, _________________________________ [Instruction: Insert the Name of the Grantor], of
__________________________________ [Instruction: Insert the Address of Grantor], City
of __________________ [Instruction: Insert the City], County of _______________________
[Instruction: Insert the County], State of Alaska, Grantor, having executed an Advance Health
Care Power of Attorney on or about the ____ [Month] ____ [Date], 20____, to
__________________________ [Instruction: Insert the Name of Attorney-in-Fact/agent] my
Attorney-in-Fact/agent, to act in my behalf as my true and lawful attorney regarding certain
choices and decision I had made concerning the use of artificial life sustaining procedure,
hereby revoke that Power of Attorney pursuant to its explicit provision that it may be revoked by
me by written instrument signed by me and delivered to my Attorney-in-Fact/Agent.
This is my written revocation of the above referenced Power of Attorney and I am providing a
copy of it to my Attorney-in-Fact/Agent.
Signature of Grantor : ____________________________________________
Printed Name of Grantor : ______________________________________________
Witness Signature #1 : ____________________________________________
Name : _____________________________________________
Address : _____________________________________________
Witness Signature #2 : ____________________________________________
Name : _____________________________________________
Address : _____________________________________________
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