By this codicil dated this ____________________ day of ___________________________

200__

made by me ______________________________________________________________
 

of ______________________________________________________________________
 

________________________________________________________________________
 

________________________________________________________________________
 
 

as a Codicil to my Will (“my Will”) dated _____________ day of _______________________

(year) ____________

1. I hereby give to Holy Rood House, Centre for Health and Pastoral Care

The sum of _________________________________

(words) __________________________________________________________________
 

2. In all other respects I confirm the terms of my said will.
 

Signature ____________________________________
 

Signed by the testator/testatrix as a codicil to his/her Will in our presence and attested by us in the presence of him/her and of 
each other.
 

Witness 1                                  Signed ________________________________ 
 
Address ________________________________________________________________
 
_______________________________________________________________________
 

Witness 2                                  Signed ________________________________
  
Address ________________________________________________________________

_______________________________________________________________________