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| Revocation of Health Care Durable Power of Attorney |
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I, __________________, (“Declarant”), of ____________________________________ (Address), do hereby revoke any and all power and authority granted to my physician, health care provider, or health care agent in the past, but especially the previous Health Care Durable Power Attorney attached in Exhibit 1, and dated _________________, appointing ________________________ to act as my health care Agent. All such Durable Power of Attorney’s, including but not limited to the one named above, are hereby revoked and withdrawn and this document provides notice of such revocation. ______________________ ___________________________ Declarant My Physician I acknowledge and declare I am not the Declarant's spouse or heir at the time of witnessing this document, nor am I associated with any health care facility in which Declarant resides or uses in any manner whatsoever. ____________________________ Witness Signature: Witness Name: Witness Address: ____________________________ Witness Signature: Witness Name: Witness Address: Names of institutions/individuals who have been provided a copy of this revocation: Should include all parties receiving prior Agreement and the signatory thereto, “My Physician.” |
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