Revocation of Advance Health Care Directive Power of Attorney


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									This document is intended to be used to revoke the power of attorney that is granted to
a third party allowing them to make health care related decisions on behalf of a
principal. For this revocation to be valid, the original agreement granting the power of
attorney must have a clause that allows revocation. Particularly, this document revokes
the third party’s power of making artificial life sustaining procedure decisions. This
document can be used by individuals that want to revoke the power of attorney they
have granted a third party allowing them to make medical related decisions on their

                                      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 _________________, 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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