Fill and Sign the As My Attorney in Factsurrogate Form

REVOCATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE I, ___________________________________________________________________, Declarant, executed an Advance Directive for Health Care on the ________ day of ________________________, 20____, appointing __________________________________________________________________________________ as my attorney in fact/surrogate [choose one] to make health care decisions for me.New Hampshire Revised Statutes Code § 137-J:15 provides that an advance directive for healthcare may be revoked: (a) By written revocation delivered to the agent or surrogate or to a health care provider or residential care provider expressing the principal's intent to revoke, signed and dated by the principal; by oral revocation in the presence of 2 or more witnesses, none of whom shall be the principal's spouse or heir at law; or by any other act evidencing a specific intent to revoke the power, such as by burning, tearing, or obliterating the same or causing the same to be done by some other person at the principal's direction and in the principal's presence; (b) By execution by the principal of a subsequent advance directive; (c) By the filing of an action for divorce, legal separation, annulment or protective order, where both the agent and the principal are parties to such action, except when there is an alternate agent designated, in which case the designation of the primary agent shall be revoked and the alternate designation shall become effective. Re-execution or written re-affirmation of the advance directive following a filing of an action for divorce, legal separation, annulment, or protective order shall make effective the original designation of the primary agent under the advance directive; or (d) By a determination by a court under RSA 506:7 that the agent's authority has been revoked.This is my written revocation of my Advance Directive for Health Care and is provided to all persons to whom I have provided a copy of my Advance Directive for Health Care, including the person I appointed as my attorney in fact, agent, or surrogate.DATED this the _________ day of ______________________________, 20____. Signature of Declarant: ___________________________________________Printed Name of Declarant: ___________________________________________Address of Declarant: ________________________________________________________________________________________________Signature of Witness: ___________________________________________Printed Name of Witness: ___________________________________________Address of Witness: ________________________________________________________________________________________________Signature of Witness: ___________________________________________Printed Name of Witness: ___________________________________________ Address of Witness: ________________________________________________________________________________________________