I, __________________________, being of sound mind and body, do
not wish to be kept alive indefinitely by artificial means. Under no circumstances should my fate be put in the hands of pinhead politicians who couldn't pass ninth-grade biology if their lives
depended on it or lawyers/doctors interested in simply running up
the bills. If a reasonable amount of time passes and I fail to ask for at least one of the following

   ______a Bloody Mary
   ______a Margarita
   ______a Crown and Coke
   ______a steak
   ______Chicken Fried Steak with mashed potatoes and gravy
   ______Lobster or crab legs
   ______the remote control
   ______a bowl of French vanilla ice cream
   ______the sports page
   ______sex

it should then be presumed that I won't ever get better. When such a determination is reached, I hereby instruct my appointed person and attending physicians to pull the plug, reel in the tubes
and call it a day.

Signature:         ___________________________

Date:                ___________________________