Fill and Sign the Georgia Statutory Form

REVOCATION OF STATUTORY ADVANCE DIRECTIVE FOR HEALTH CARE I, _________ John Doe __________________________________________________________, Declarant, having executed an Advance Directive for Health Care on the __ 1st ______ day of _ October _______________________, 2__ 007 __. Georgia Code §31-32-6(a) provides that an advance directive for health care may be revoked by any of the following methods: (1) By completing a new advance directive for health care that has provisions which are inconsistent with the provisions of a previously executed advance directive for health care, living will, or durable power of attorney for health care; provided, however, that such revocation shall extend only so far as the inconsistency exists between the documents and any part of a prior document that is not inconsistent with a subsequent document shall remain unrevoked; (2) By being obliterated, burned, torn, or otherwise destroyed by the declarant or by some person in the declarant's presence and at the declarant's direction indicating an intention to revoke; (3) By a written revocation clearly expressing the intent of the declarant to revoke the advance directive for health care signed and dated by the declarant or by a person acting at the declarant's direction; or (4) By an oral or any other clear expression of the intent to revoke the advance directive for health care in the presence of a witness 18 years of age or older who, within 30 days of the expression of such intent, signs and dates a writing confirming that such expression of intent was made. This is my written revocation of the above referenced Advanced Directive for Health Care and I am providing a copy of this revocation to all parties to whom I provided a copy of the original advance directive, including my agent. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: __ John Doe ___________________________________ Address of Declarant: __ 123 First Street, Madison, GA 12345 ____________________ Signed and executed in the presence of: ___________________________ ___________________________ Witness Witness