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Fill and Sign the Revocation of Statutory Equivalent of Living Will or Declaration Rhode Island Form

Fill and Sign the Revocation of Statutory Equivalent of Living Will or Declaration Rhode Island Form

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REVOCATION OF DECLARATION I, ___________________________________________________________________, Declarant, having executed a Declaration regarding the use of life sustaining procedures on the ________ day of ___________________________________________________________, 20____. Rhode Island General Laws § 23-4.11-4 provides that a declaration may be revoked at any time and in any manner by which I am able to communicate an intent to revoke, without regard to my mental or physical condition. This is my written revocation of the above referenced Declaration and I am providing a copy of it to all persons to whom I provided a copy of the Declaration. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________

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