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Fill and Sign the Revocation of Directive to Physicians and Providers of Medical Services for Persons Signing Instrument on Behalf of Declarant Form

Fill and Sign the Revocation of Directive to Physicians and Providers of Medical Services for Persons Signing Instrument on Behalf of Declarant Form

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REVOCATION OF DIRECTIVE TO PHYSICIANS AND PROVIDERS OF MEDICAL SERVICES (Pursuant to Section 75-2-1105, et seq.UCA) I,       , Declarant, having executed a Directive to Physicians and Providers of Medical Services on the       day of       , 20       , on behalf of       . The Utah Code 75-2-1111 provides that this Directive may be revoked at any time by me by: (a) being obliterated, burned, torn, or otherwise destroyed or defaced in any manner indicating an intention to effect revocation; (b) a written revocation of the directive signed and dated by the declarant or by a person signing on behalf of the declarant or acting at the direction of the declarant; (c) oral expression of an intent to revoke the directive in the presence of a witness 18 years of age or older who signs and dates a written instrument confirming that the expression of intent was made. This is my written revocation of the above referenced Directive and I am providing a copy of it to all concerned parties. DATED this the       day of       , 20       . Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant:      

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