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Fill and Sign the Revised Statutes of Nebraska 20 406 Form

Fill and Sign the Revised Statutes of Nebraska 20 406 Form

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REVOCATION OF DECLARATION (Revised Statutes of Nebraska §20-406) I, ___________________________________________________________________, Declarant, executed a Declaration relating to use of life-sustaining treatment on the ________ day of ________________________, 20____. Revised Statutes of Nebraska §20-406 provides that a declarant may revoke a declaration at any time and in any manner, without regard to the declarant's mental or physical condit ion, and that a revocation shall be effective upon its communication to the attending physician or other health care provider by the declarant or a witness to the revocation. This is my written revocation of my Declaration and is provided to all persons to whom I have provided a copy of my Declaration. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________

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