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 Steak

______a Martini

______a cold beer

______a Margarita

______a Bloody Mary

______a glass of wine

______a Vodka and Tonic

______a Scotch and soda

______ a Bourbon on the rocks

______Lobster or crab legs

______a Bowl of ice cream

______The remote control

______The sports page

______ a new rifle

______Chocolate

______Sex

it should 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: ___________________________