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Maxine 1
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:

______ Glass of wine

______ Margarita

______ Martini

______ Cold Beer

______ Chicken fried steak and cream gravy

______Mexican food

______ French fries

______ Pizza

______ Bowl of ice cream

______ Cup of tea

______ Chocolate

______ All of the above,

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.

Maxine 2



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