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Revocation Of Living Will

§ 31-32-5 Form 1 Revocation Of Living Will

STATE OF GEORGIA

COUNTY OF ___________

I, ____________, the declarant of a living will dated the ___________ day of

___________, 20__, do hereby make and publish this revocation of said living will, and

to that end, do hereby declare as follows:

It is my present, express intent to revoke my living will referred to above, as well as

any and all other living will or living wills by me heretofore made, and I specifically

desire and direct that said living will shall be from this moment forward as completely

null, void, and ineffectual as if the same had never been executed by me.

This revocation is intended specifically to revoke only my living will as opposed to

my Last Will and Testament relating to the disposition of my property after my death,

and this revocation shall not in any way operate to impair or revoke my said Last Will

and Testament.

I desire and direct that this revocation immediately be communicated to Dr.

___________, my attending physician, and to any other physician or physicians who

have attended me during the period from the date of the execution of my living will

referred to above until the present. I further direct that a copy of this revocation be made

a part of my permanent medical record.

IN WITNESS WHEREOF, I have hereunto set my hand, as of ___________ o'clock

__. m. on this ___________ day of ___________, 20__.

__________________

Signature of declarant

__________________

Witness

(Include the following attestation if the declarant is unable to sign:)

I hereby certify that, acting at the special instance, request, and direction of

____________, the declarant of the living will referred to hereinabove, I have dated and

signed this revocation on behalf of said declarant, who is unable to sign for himself (or

herself).

/s/ ____________

(Sign declarant's name)

_______________________

(Signature of person signing)

Revocation Of Living Will