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State of Ohio Advance Directives Health Care Power of Attorney Form
Attorney-in-fact/Agent.
This is my written revocation of the above referenced General Durable Power of Attorney and I
am providing a copy of it to my attorney-in-fact/Agent.
DATED this the _________ day of ______________________________, 20____.
Signature of Declarant: __________________________________________________________
Printed Name of Declarant: _______________________________________________________
Address of Declarant:...
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