As Amended
SEC. 41-41-109. Revocation of declaration; form.
(1) A declaration executed as provided in section 41-41-107 may be revoked by a revocation signed by the declarant and at least two (2) persons who witnessed the declarant's execution of the revocation which shall be in substantially the following form:
On ---- (date), I, ----, (person's name), of ---- (address), ---- (Social Security Number), being of sound mind, revoke the declaration made on ---- (date declaration made) regarding the manner in which I die.
SIGNED ______________
I hereby witness this revocation and attest that:
(1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind.
(2) To the best of my knowledge, at the time of the execution of this revocation, I:
(a) Am not related to the maker of this revocation by blood or marriage,
(b) Do not have any claim on the estate of the maker of this revocation,
(c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law, and
(d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.
WITNESS ______________
ADDRESS ______________
SOCIAL SECURITY NUMBER ________
WITNESS ______________
ADDRESS ______________
SOCIAL SECURITY NUMBER ________
(2) The revocation shall be filed with the bureau of vital statistics of the state board of health.
(3) If a declarant wishes to revoke the authorization of life-sustaining mechanisms but is unable physically to execute a revocation as provided in this section, a clear expression by the declarant, oral or otherwise, of the declarant's wish to revoke the authorization is effective as a revocation of the authorization.
(4) An attending physician having actual knowledge or reason to believe that his patient has executed a declaration in conformance with sections 41-41-101 et seq. may ask the declarant, prior to procedures which might reasonably be expected to cause the declarant to become permanently unconscious or unable to make his wishes known, if said declarant revokes his declaration. The physician's determination of declarant's response in such situations shall be final.
SOURCES: Laws, 1984, ch. 365, Sec. 5, eff from and after July 1, 1984.