Declaration Of A Desire For A Natural Death Form Page 3
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4DECLARATION. AN ORAL REVOCATION COMMUNICATED TO THE ATTENDING
PHYSICIAN BY A PERSON OTHER THAN YOU IS EFFECTIVE ONLY IF:
(A) THE PERSON WAS PRESENT WHEN THE ORAL REVOCATION WAS MADE;
(B) THE REVOCATION WAS COMMUNICATED TO THE PHYSICIAN WITHIN A
REASONABLE TIME;
(C) YOUR PHYSICAL OR MENTAL CONDITION MAKES IT IMPOSSIBLE FOR
THE PHYSICIAN TO CONFIRM THROUGH SUBSEQUENT CONVERSATION
WITH YOU THAT THE REVOCATION HAS OCCURRED.
TO BE EFFECTIVE AS A REVOCATION, THE ORAL EXPRESSION CLEARLY MUST
INDICATE YOUR DESIRE THAT THE DECLARATION NOT BE GIVEN EFFECT OR
THAT LIFE-SUSTAINING PROCEDURES BE ADMINISTERED;
(4) IF YOU, IN THE SPACE ABOVE, HAVE AUTHORIZED AN AGENT TO REVOKE THE
DECLARATION, THE AGENT MAY REVOKE ORALLY OR BY A WRITTEN, SIGNED,
AND DATED INSTRUMENT. AN AGENT MAY REVOKE ONLY IF YOU ARE
INCOMPETENT TO DO SO. AN AGENT MAY REVOKE THE DECLARATION
PERMANENTLY OR TEMPORARILY.
(5) BY YOUR EXECUTING ANOTHER DECLARATION AT A LATER TIME.
__________________________________________
Declarant
STATE OF SOUTH CAROLINA
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AFFIDAVIT
COUNTY OF _____________
)
We, _________________________ and __________________________, the undersigned
witnesses to the foregoing Declaration, dated this _____ day of ________________, 20__, at
least one of us being first duly sworn, declare to the undersigned authority, on the basis of our
best information and belief, that the Declaration was on that date signed by the Declarant as and
for his/her DECLARATION OF A DESIRE FOR A NATURAL DEATH in our presence and
we, at his/her request and in his/her presence, and in the presence of each other, subscribe our
names as witnesses on that date. The Declarant is personally known to us, and we believe
him/her to be of sound mind. Each of us affirms that he/she is qualified as a witness to this
Declaration under the provisions of the South Carolina Death With Dignity Act in that he/she is
not related to the Declarant by blood, marriage, or adoption, either as a spouse, lineal ancestor,
descendant of the parents of the Declarant, or spouse of any of them; nor directly financially
responsible for the Declarant's medical care; nor entitled to any portion of the Declarant's estate
upon his decease, whether under any will or as an heir by intestate succession; nor the
beneficiary of a life insurance policy of the Declarant; nor the Declarant's attending physician;
nor an employee of the attending physician; nor a person who has a claim against the Declarant's
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