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Fill and Sign the Virginia Revocation 497428430 Form

Fill and Sign the Virginia Revocation 497428430 Form

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REVOCATION OF ADVANCE MEDICAL DIRECTIVE (Code of Virginia § 54.1-2985) I, ___________________________________________________________________, Declarant, executed an Advance Medical Directive on the ________ day of ________________________, 20____, regarding my decisions and choice that my life not be prolonged by extraordinary means and exercising certain other options available to me. The Code of Virginia § 54.1-2985 provides that " An advance directive may be revoked at any time by the declarant (i) by a signed, dated writing; (ii) by physical cancellation or destruction of the advance directive by the declarant or another in his presence and at his direction; or (iii) by oral expression of intent to revoke…." This is my written revocation of my Advance Medical Directive and is provided to all persons to whom I have provided a copy of my Advance Medical Directive. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________

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