#5900
@001 Please state the name of the person revoking:
@002 Please state the Month, date of the last known living will:
@003 State the year that the last known living will was signed:
@004 Please enter the social security number of signer:
@005 Please state the street address of the signer:
@006 Please state the city, state of the signer:
@007 Please enter the State in which signed:
@008 Please enter the County in which signed:
#end control section
#5900
/* Here's a revocation of living will.*/


		REVOCATION OF LIVING WILL



STATE OF @007)


COUNTY OF @008)



	WHEREAS, on @002, @003, I, @001, executed a "living will"
(or a similar document styled as a "declaration" or "directive 
to physicians") which provided that upon a terminal diagnosis, 
and my inability to communicate decisions regarding the course of 
my treatment to my physicians, that no extraordinary means be
used to simply prolong my life.


	At this time, and after mature reflection, I have
determined that I do not desire for this instrument to have
further effect, and I therefore revoke the same.



Dated: __________________________________





                ________________________________________________

                Declarant: @001

                Address: @005

                         @006


                Social Security Number: @004



	I/We, the undersigned witnessed the Declarant sign
this instrument and believe him or her to be of sound mind.




                ________________________________________________

                Witness:


                Address:





                ________________________________________________

                Witness:


                Address:



STATE OF @007


COUNTY OF @008



	Before me, the undersigned Notary Public personally appeared

@001, and the witnesses above, who all acknowledged

that they executed this instrument freely and willingly for the

purposes therein stated.





                 ________________________________________________

                 Notary Public

                 My commission expires: