SECRETARY OF THE STATE OF NORTH CAROLINA
Advance Health Care Directive Registry
P.O. Box 29622
Raleigh, NC 27626-0622
Website: https://www.sosn/gov
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. Registrant’s Full Name: __________________________________________________
2. Registrant’s File Number: ________________________________________________
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.
Registrant’s Signature: _____________________________________________
******************************************************************************
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
Notary’s printed or typed name
My commission expires:_______________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
