Removal Form

SECRETARY OF THE STATE OF NORTH CAROLINA Advance Health Care Directive Registry P.O. Box 29622 Raleigh, NC 27626-0622 Website: http://www.s REMOVAL FORM Please complete the information listed below in order to withdraw your health care directive information from our database. When completed, YOUR SIGNATURE MUST BE NOTARIZED BY A COMMISSIONED NOTARY. Please delete my documents from the Advance Health Care Directive Registry. 1.2.3.Check the health care directives that you wish to remove from the registry. A health care power of attorney; Advance directive for a natural death (living will); An advance instruction for mental health treatment; or A declaration of an anatomical gift. I understand that the deletion of these records from the registry does not 1) affect the validity of the document(s) in whole or in part, 2) relate to the accuracy of the information contained in the document(s), and 3) create a presumption regarding the validity of the document, regarding the accuracy of information contained in the document(s) or that the statutory requirements for the document(s) have been met. ****************************************************************************** STATE OF SEAL COUNTY OF Signed and sworn to (or affirmed) before me this day by . Name of Declarant Witness my hand and official seal, this the day of , 20. Official Signature of Notary , Notary My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com