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Fill and Sign the Revocation of Life Prolonging Procedures Declaration Indiana Form

Fill and Sign the Revocation of Life Prolonging Procedures Declaration Indiana Form

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REVOCATION OF LIFE PROLONGING PROCEDURES DECLARATION I, ___________________________________________________________________, Declarant, executed a Life Prolonging Procedures Declaration on the ________ day of ________________________, 20____. IC 16-36-4-12 provides that a living will declaration or a life prolonging procedures will declaration may be revoked at any time by the declarant by any of the following: (1) A signed, dated writing. (2) Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction. (3) An oral expression of intent to revoke. This is my written revocation as indicated above of my Declaration and is provided to all persons to whom I have provided a copy of that Declaration. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: ____________________________________________________ Printed Name of Declarant: _________________________________________________ Address of Declarant: _____________________________________________________

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