(3) BY YOUR ORAL EXPRESSION OF YOUR INTENT TO REVOKE THE
DECLARATION. 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 )
) 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
DECLARATION OF A DESIRE FOR A NATURAL DEATH in our presence and we, at her
request and in 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 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