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Delaware ________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- his _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me t_ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: _______________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: __________________________________acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at ___________________l not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while le Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shal third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this Durabto a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the(a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of my Agent; and/or (c) my assets to be subject er-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are limited to the extent necessary to prevent fected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this powrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaf and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restn for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handledentitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensatioe and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. My Agent shall be on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receivin writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. This Power of Attorney shall not terminate rectly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my subsequent disability or incapacity as certified any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, if the result is that the disclaimed assets pass diust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from ions, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trof appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligatassign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers ar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendt tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers angible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gifncy, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, ther governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any ageited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or otess that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limcontents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. 12. To maintain and/or operate any businosit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the orm any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. -2- 10. To have access to any safe depuments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perfusiness with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instrhecking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any banyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, c any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and performppropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension,y reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other a may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me b(now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own orest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible le, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvts, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due in the future, owned by, due, owing payabst any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposik, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf againases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, asal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawry to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deall lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessaause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and l, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or c act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or persona___________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ maintaining an address at: ____________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-inLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _____________________________________revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- DURABbinding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may al matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of attorney document, is legally of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legic. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specifcord, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, if the Agent will deal with eal property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public reis unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any r of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event the original Agent the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since this Durable Powernt and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especially important if n acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorney is a "powerful" instrumecipal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here to mean "lawyer". The perso allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalf, even if the Prinase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability A Durable Power of Attorneyhould only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with another party. [_] The purchserve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal advice. These forms susiness and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to serve or continue to he Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent has the power to handle bginal document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks t real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, Agent or Notary should not be a witness. [_] The Principal should keep the oriecord, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will be dealing with anyincipal. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recorded as a public rtion for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the Disability of the PrInstructions & Checklist Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) Informa DelawareDelaware of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow DelawareDelaware _ Date: _________________________________________ -5- aware Code from being a witness. _____________________________________________ (Second Witness Signature) Print Name: ___________________________________ Address: _____________________________________e) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ I am not prohibited by § 2503 of Title 16 of the DelPhysical Disabilities or the Public Guardian. I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. _____________________________________________ (First Witness Signatur of the witnesses, ____________, is at the time of the execution of the advance health-care directive, a patient advocate or ombudsman designated by the Division of Services for Aging and Adults with n in which the declarant is a resident; or 6. Is under eighteen years of age. C. That if the declarant is a resident of a sanitarium, rest home, nursing home, boarding home or related institution, oneeclarant; 4. Has a direct financial responsibility for the declarant's medical care; 5. Has a controlling interest in or is an operator or an employee of a residential long-term health-care institutiois so entitled by operation of law then existing; -4- 3. Has, at the time of the execution of the advance health-care directive, a present or inchoate claim against any portion of the estate of the d; 2. Is entitled to any portion of the estate of the declarant under any will of the declarant or codicil thereto then existing nor, at the time of the executing of the advance health care directive, h other, have hereunto subscribed our names as witnesses, and state: A. That the Declarant is mentally competent. B. That neither of them: 1. Is related to the declarant by blood, marriage or adoption DECLARED by the above-named declarant as and for his/her written declaration under 16 Del.C. §§ 2502 and 2503, in our presence, who in his/her presence, at his/her request, and in the presence of eac_________________ (Declarant's Signature) Print Name: ___________________________________ Address: ______________________________________ (7) SIGNATURES OF WITNESSES: Statement Of Witnesses SIGNED ANDthe same effect as the original. (6) SIGNATURE: Sign and date the form here: I understand the purpose and effect of this document. Date: _____________________________________ _________________________ health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility. (5) EFFECT OF COPY: A copy of this form has _______________________________________ Primary Physician shall mean a physician designated by an individual or the individual's agent or guardian, to have primary responsibility for the individual's__________________ (name of physician) _____________________________________________________________________________ (address) (city) (phone) (state) (zip code) ______________________________________not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physician: -3- ________________________________________________________________________________ (address) (city) (phone) (state) (zip code) _____________________________________________________________________________ OPTIONAL: If the physician I have designated above is following physician as my primary physician: _____________________________________________________________________________ (name of physician) ________________________________________________________________ for the following purposes: [ [ [ [ [ ] any purpose authorized by law; ] transplantation; ] therapy; ] research; ] medical education. PART 3: PRIMARY PHYSICIAN (OPTIONAL) (4) I designate the] the following named physician, hospital, storage bank or other medical institution: __________________________________________________; [ ] the following individual for treatment: __________________d organs or parts; [ ] the following organs or parts _________________________; To the following person or institutions [ ] the physician in attendance at my death; [ ] the hospital in which I die; [ 2- I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. I give: [ ] my body; [ ] any neede__________ (Add additional sheets if needed.) _____ I do not want used _____ I do not want used PART 2 ANATOMICAL GIFTS AT DEATH (OPTIONAL) (3) I am mentally competent and 18 years or more of age. -ave given above, you may do so here.) I direct that: ______________________________________________________________________________ ____________________________________________________________________________________________________ (2) OTHER MEDICAL INSTRUCTIONS: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you h pain or discomfort be provided at all times, even if it hastens my death: ______________________________________________________________________________ ______________________________________________ife to be prolonged as long as possible within the limits of generally accepted health-care standards. RELIEF FROM PAIN: Except as I state in the following space, I direct treatment for alleviation ofration, I make the following specific directions: Artificial nutrition through a conduit _______ I want used Hydration through a conduit _______ I want used Choice To Prolong Life ________ I want my lf consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma) and regarding artificial nutrition and hydedical condition that has been diagnosed in accordance with currently accepted medical standards that has lasted at least 4 weeks and with reasonable medical certainty as total and irreversible loss ol nutrition through a conduit _______ I want used Hydration through a conduit _______ I want used _____ I do not want used _____ I do not want used ________ (ii) I become permanently unconscious (a mfrom which, despite the application of life-sustaining procedures, there can be no recovery) and regarding artificial nutrition and hydration, -1- I make the following specific directions: Artificiaeck all that apply) ________ (i) I have a terminal condition (an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and d others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: Choice Not To Prolong Life I do not want my life to be prolonged if: (please chce health-care directive or replace this form at any time. PART 1: INSTRUCTIONS FOR HEALTH CARE (1) END-OF-LIFE DECISIONS: If I am in a qualifying condition, I direct that my health-care providers ano any other health-care providers you may have, to any health-care institution at which you are receiving care and to any health-care agents you may have named. You have the right to revoke this advanhealth care. After completing this form, sign and date the form at the end. It is required that 2 other individuals sign as witnesses. Give a copy of the signed and completed form to your physician, t 2 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 3 of this form lets you designate a physician to have primary responsibility for your well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional instructions for other than end of life decisions. Part Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration asyou use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form lets you give specific instructions about any aspect of your health care. own health care. This form lets you to give instructions about your own health care. It also lets you express your wishes regarding anatomical gifts and the designation of your primary physician. If nal. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Living Will Explanation You have the right to give instructions about yoursituation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professioarting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a stving such emergency treatment. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their revokes the earlier directive to the extent of the conflict. -3- (f) The initiation of emergency treatment shall be presumed to represent a suspension of an advance health-care directive while receipouse as an agent unless otherwise specified in the decree or in a power of attorney for health care. (e) An advance health-care directive that conflicts with an earlier advance health-care directive health-care institution at which the patient is receiving care. (d) A decree of annulment, divorce, dissolution of marriage or a filing of a petition for divorce revokes a previous designation of a st not limited to, a health care provider, agent or guardian, who is informed of a revocation shall immediately communicate the fact of the revocation to the supervising health-care provider and to any(b) Any revocation that is not in writing shall be memorialized in writing and signed and dated by both witnesses. This record shall be made a part of the medical record. (c) Any person, including, bu an advance healthcare directive: (1) By a signed writing; or (2) In any manner that communicates an intent to revoke done in the presence of 2 competent persons, 1 of whom is a health care provider. ide the uterus with the continued application of a life-sustaining procedure. § 2504. Revocation of advance health-care directive. (a) An individual who is mentally competent may revoke all or part of a guardian of the person. (j) A life-sustaining procedure may not be withheld or withdrawn from a patient known to be pregnant, so long as it is probable that the fetus will develop to be viable outs operator or employee of a residential long-term healthcare institution at which the principal is receiving care. (i) A written advance health-care directive may include the individual's nomination ofon made by an agent for a principal is effective without judicial approval. (h) Unless related to the principal by blood, marriage or adoption, an agent may not have a controlling interest in or be ant the agent knows and is able to determine, the agent's decision is to take into account, including, but not limited to, the factors, if applicable, stated in this subsection. (g) A health-care decisirs. -2- If the agent is unable to determine what the patient would have done or intended under the circumstances, the agent's decision shall be made in the best interest of the patient. To the extenpatient; and (5) Reliable oral or written statements previously made by the patient, including, but not limited to, statements made to family members, friends, health care providers or religious leadelosophical, religious and ethical values; (2) The patient's likelihood of regaining decision making capacity; (3) The patient's likelihood of death; (4) The treatment's burdens on and benefits to the e extent that the agent knows or is able to determine, the agent's decision is to take into account, including, but not limited to, the following factors if applicable: (1) The patient's personal, phit's instructions or wishes are not known or clearly applicable, the agent's decision shall conform as closely as possible to what the patient would have done or intended under the circumstances. To thhysician designated pursuant to subsection (e) of this section, and in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent. If the patiencity. (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after consultation with the attending physician or with the person other than a pccommodating an individual's religious or moral beliefs. That provision may designate a person other than a physician to certify in a notarized document that the individual lacks or has recovered capauthority of an agent must be made by the primary physician or other physician(s) as specified in a written health-care directive; however, a power of attorney for health care may include a provision as to be effective upon a determination that the declarant has recovered capacity. (e) A determination that an individual lacks or has recovered capacity that affects an individual instruction or the aocedure, the advance health-care directive shall become effective only upon a determination that the declarant lacks capacity and has a qualifying condition. (d) An advance health-care directive ceasee effective only upon a determination that the declarant lacks capacity, and when the advance health-care directive is to be applied to the providing, withholding or withdrawal of a life-sustaining pr (2) Each witness to the advance health-care directive shall state in writing that he or she is not prohibited under this section from being a witness. (c) An advance health-care directive shall becomesponsibility for the declarant's medical care; or -1- 5. Has a controlling interest in or is an operator or an employee of a health care institution at which the declarant is a patient or resident.aw then existing; 3. Has, at the time of the execution of the advance health care directive, a present or inchoate claim against any portion of the estate of the declarant; 4. Has a direct financial rhe declarant under any will or trust of the declarant or codicil thereto then existing nor, at the time of the executing of the power of attorney for health care, is entitled thereto by operation of lction; c. Dated; d. Signed in the presence of 2 or more adult witnesses neither of whom: 1. Is related to the declarant by blood, marriage or adoption; 2. Is entitled to any portion of the estate of thile having capacity. (b) (1) An advance health-care directive must be: a. In writing; b. Signed by the declarant or by another person in the declarant's presence and at the declarant's expressed diretake effect only if a specified condition arises; and/or (2) Execute a power of attorney for health care, which may authorize the agent to make any health-care decision the principal could have made w. § 2503. Advance health-care directives. (a) Subject to the limitations of this chapter, an adult who is mentally competent may: (1) Give an individual instruction. The instruction may be limited to in part on Title 16 Chapter 25 Section 2503 et. Seq. of the Delaware Statutes. The following are useful excerpts from the Delaware Statutes relating to the Delaware Advance Health Care Directive FormInformation and Instructions Delaware Living Will This package contains (1) Information and Instruction for Delaware Living Will Form; (2) Delaware Living Will Form. This Delaware Living Will is based DelawareDelaware _________________________ Address: ______________________________________ Date: _________________________________________ -7- _____________ -6- I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. _____________________________________________ (Second Witness Signature) Print Name: _____________________________________________________ (First Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: ____________________________ designated by the Division of Services for Aging and Adults with Physical Disabilities or the Public Guardian. I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. __rest home, nursing home, boarding home or related institution, one of the witnesses, ____________, is at the time of the execution of the advance health-care directive, a patient advocate or ombudsmanr or an employee of a residential long-term health-care institution in which the declarant is a resident; or 6. Is under eighteen years of age. C. That if the declarant is a resident of a sanitarium, esent or inchoate claim against any portion of the estate of the declarant; 4. Has a direct financial responsibility for the declarant's medical care; 5. Has a controlling interest in or is an operatoor, at the time of the executing of the advance health care directive, is so entitled by operation of law then existing; 3. Has, at the time of the execution of the advance health-care directive, a pr of them: 1. Is related to the declarant by blood, marriage or adoption; 2. Is entitled to any portion of the estate of the declarant under any will of the declarant or codicil thereto then existing nwho in his/her presence, at his/her request, and in the presence of each other, have hereunto subscribed our names as witnesses, and state: A. That the Declarant is mentally competent. B. That neither__ -5- (11) SIGNATURES OF WITNESSES: Statement Of Witnesses SIGNED AND DECLARED by the above-named declarant as and for his/her written declaration under 16 Del.C. §§ 2502 and 2503, in our presence, : _____________________________________ __________________________________________ (Declarant's Signature) Print Name: ___________________________________ Address: ____________________________________the responsibility. (9) EFFECT OF COPY: A copy of this form has the same effect as the original. (10) SIGNATURE: Sign and date the form here: I understand the purpose and effect of this document. Dateor guardian, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes tate) (zip code) _____________________________________________________________________________ (phone) Primary Physician shall mean a physician designated by an individual or the individual's agent ian: _____________________________________________________________________________ (name of physician) _____________________________________________________________________________ (address) (city) (s______ (phone) OPTIONAL: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physicof physician) _____________________________________________________________________________ (address) (city) (state) (zip code) _______________________________________________________________________cation. -4- PART 3: PRIMARY PHYSICIAN (OPTIONAL) (8) I designate the following physician as my primary physician: _____________________________________________________________________________ (name _; [ ] the following individual for treatment: __________________________ for the following purposes: [ [ [ [ [ ] any purpose authorized by law; ] transplantation; ] therapy; ] research; ] medical eduan in attendance at my death; [ ] the hospital in which I die; [ ] the following named physician, hospital, storage bank or other medical institution: _________________________________________________ks below indicate my desires. I give: [ ] my body; [ ] any needed organs or parts; [ ] the following organs or parts _________________________; To the following person or institutions [ ] the physici(OPTIONAL) (7) I am mentally competent and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blan__________________________________________________ ______________________________________________________________________________ (Add additional sheets if needed.) PART 2: ANATOMICAL GIFTS AT DEATH gree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: _____________________________________________________________________________ __________________________________________________ [ ] I do not nominate anyone to be guardian. -3- (6) OTHER MEDICAL INSTRUCTIONS: (If you do not aagent(s) whom I named in this form in the order designated to act as guardian. [ ] I nominate the following to be guardian in the order designated: __________________________________________________ _all consider my personal values to the extent known to my agent. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, (please check one): [ ] I nominate the the extent my wishes are unknown, my agent shall make health-care decisio ns for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the capacity to make my own health-care decisions and my primary physician and another physician determine I am in a terminal condition or permanently unconscious. (4) AGENT'S OBLIGATION: My agent shlth-care decisions. As to decisions concerning the providing, withholding and withdrawal of lifesustaining procedures my agent's authority becomes effective when my primary physician determines I lack___ (Add additional sheets if needed.) (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines I lack the capacity to make my own heaare decisions for me, except as I state here: ______________________________________________________________________________ ___________________________________________________________________________ized to make all health-care decisions for me, except decisions about life-sustaining procedures and as I state here; and if I am in a qualifying condition, my agent is authorized to make all health-cp code) _____________________________________________________________________________ -2- (home phone) (work phone) (2) AGENT'S AUTHORITY: If I am not in a qualifying condition my agent is author___________________________________ (name of individual you choose as second alternate agent) _____________________________________________________________________________ (address) (city) (state) (ziirst alternate agent or if neither is willing, able, or reasonably available to make a health-care decision for me, I designate as my second alternate agent: ______________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke the authority of my agent and f_____________________________________________________________________ (name of individual you choose as first alternate agent) _________________________________________________________________________phone) OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health-care decision for me, I designate as my first alternate agent: _________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work llowing individual as my agent to make health-care decisions for me: _____________________________________________________________________________ (name of individual you choose as agent) ____________nsibility. You have the right to revoke this power of attorney for health care or replace this form at any time. PART 1: POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the foreceiving care and to any health-care agents you have named. You should talk to the person you have named as agent to make sure that the person understands your wishes and is willing to take the respoer individuals sign as witnesses. Give a copy of the signed and completed form to your physician, -1- to any other health-care providers you may have, to any health-care institution at which you are death. Part 3 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. It is required that 2 otholding or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of this form lets you express an intention to donate your bodily organs and tissues following yourd in (a) and (b). (d) Consent or refuse consent to life sustaining procedures, such as, but not limited to, cardiopulmonary resuscitation and orders not to resuscitate. (e) Direct the providing, withhge health-care providers and health-care institutions; If you have a qualifying condition, your agent may make all health-care decisions for you, including, but not limited to: (c) The decisions listere, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition unless it's a life-sustaining procedure or otherwise required by law. (b) Select or dischart for decisions providing, withholding or withdrawing of a life sustaining procedure. Unless you limit the agent's authority, your agent will have the right to: (a) Consent or refuse consent to any castitution at which you are receiving care. If you do not have a qualifying condition (terminal illness/injury or permanent unconsciousness), your agent may make all health-care decisions for you excep, able or reasonably available to make decisions for you. Unless related to you, an agent may not have a controlling interest in or be an operator or employee of a residential long-term health-care in individual as agent to make health-care decisions for you if you become incapable of making your own decisions. You may also name an alternate agent to act for you if your first choice is not willing. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name anothersions for you. This form lets you name someone else to make health-care decisions for you. It also lets you express your wishes regarding anatomical gifts and the designation of your primary physicianlforms.com -4- POWER OF ATTORNEY FOR HEALTH CARE EXPLANATION You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care deciible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegag this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possdvice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signin been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax ahall be presumed to represent a suspension of an advance health-care directive while receiving such emergency treatment. [_] These forms are provided "as is" and no implied or express warranties havedvance health-care directive that conflicts with an earlier advance health-care directive revokes the earlier directive to the extent of the conflict. -3- (f) The initiation of emergency treatment son of marriage or a filing of a petition for divorce revokes a previous designation of a spouse as an agent unless otherwise specified in the decree or in a power of attorney for health care. (e) An a communicate the fact of the revocation to the supervising health-care provider and to any health-care institution at which the patient is receiving care. (d) A decree of annulment, divorce, dissolutises. This record shall be made a part of the medical record. (c) Any person, including, but not limited to, a health care provider, agent or guardian, who is informed of a revocation shall immediately revoke done in the presence of 2 competent persons, 1 of whom is a health care provider. (b) Any revocation that is not in writing shall be memorialized in writing and signed and dated by both witnesalth-care directive. (a) An individual who is mentally competent may revoke all or part of an advance healthcare directive: (1) By a signed writing; or (2) In any manner that communicates an intent ton to be pregnant, so long as it is probable that the fetus will develop to be viable outside the uterus with the continued application of a life-sustaining procedure. § 2504. Revocation of advance hee. (i) A written advance health-care directive may include the individual's nomination of a guardian of the person. (j) A life-sustaining procedure may not be withheld or withdrawn from a patient know by blood, marriage or adoption, an agent may not have a controlling interest in or be an operator or employee of a residential long-term healthcare institution at which the principal is receiving carited to, the factors, if applicable, stated in this subsection. (g) A health-care decision made by an agent for a principal is effective witho ut judicial approval. (h) Unless related to the principales, the agent's decision shall be made in the best interest of the patient. To the extent the agent knows and is able to determine, the agent's decision is to take into account, including, but not limto, statements made to family members, friends, health care providers or religious leaders. -2- If the agent is unable to determine what the patient would have done or intended under the circumstanc) The patient's likelihood of death; (4) The treatment's burdens on and benefits to the patient; and (5) Reliable oral or written statements previously made by the patient, including, but not limited but not limited to, the following factors if applicable: (1) The patient's personal, philosophical, religious and ethical values; (2) The patient's likelihood of regaining decision making capacity; (3 possible to what the patient would have done or intended under the circumstances. To the extent that the agent knows or is able to determine, the agent's decision is to take into account, including, l instructions, if any, and other wishes to the extent known to the agent. If the patient's instructions or wishes are not known or clearly applicable, the agent's decision shall conform as closely asatient after consultation with the attending physician or with the person other than a physician designated pursuant to subsection (e) of this section, and in accordance with the principal's individuaician to certify in a notarized document that the individual lacks or has recovered capacity. (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the ph-care directive; however, a power of attorney for health care may include a provision accommodating an individual's religious or moral beliefs. That provision may designate a person other than a physdividual lacks or has recovered capacity that affects an individual instruction or the authority of an agent must be made by the primary physician or other physician(s) as specified in a written healtacks capacity and has a qualifying condition. (d) An advance health-care directive ceases to be effective upon a determination that the declarant has recovered capacity. (e) A determination that an inive is to be applied to the providing, withholding or withdrawal of a life-sustaining procedure, the advance health-care directive shall become effective only upon a determination that the declarant lnder this section from being a witness. (c) An advance health-care directive shall become effective only upon a determination that the declarant lacks capacity, and when the advance health-care directn employee of a health care institution at which the declarant is a patient or resident. (2) Each witness to the advance health-care directive shall state in writing that he or she is not prohibited ute claim against any portion of the estate of the declarant; -1- 4. Has a direct financial responsibility for the declarant's medical care; or 5. Has a controlling interest in or is an operator or axecuting of the power of attorney for health care, is entitled thereto by operation of law then existing; 3. Has, at the time of the execution of the advance health care directive, a present or inchoaclarant by blood, marriage or adoption; 2. Is entitled to any portion of the estate of the declarant under any will or trust of the declarant or codicil thereto then existing nor, at the time of the et or by another person in the declarant's presence and at the declarant's expressed direction; c. Dated; d. Signed in the presence of 2 or more adult witnesses neither of whom: 1. Is related to the demay authorize the agent to make any health-care decision the principal could have made while having capacity. (b) (1) An advance health-care directive must be: a. In writing; b. Signed by the declaranly competent may: (1) Give an individual instruction. The instruction may be limited to take effect only if a specified condition arises; and/or (2) Execute a power of attorney for health care, which s from the Delaware Statutes relating to the Delaware Advance Health Care Directive Form. § 2503. Advance health-care directives. (a) Subject to the limitations of this chapter, an adult who is mental Attorney for Health Care Form. This Delaware Power of Attorney for Health Care is based in part on Title 16 Chapter 25 Section 2503 et. Seq. of the Delaware Statutes. The following are useful excerptInformation and Instructions Delaware Power of Attorney for Health Care This package contains (1) Information and Instruction for Delaware Power of Attorney for Health Care Form; (2) Delaware Power of DelawareDelaware _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y DelawareDelaware ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa DelawareDelaware _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Delaware