The Form of Dying

Death Application
Form 136-55-B. Last modified: 1-9-2017.

Name of Applicant

Applicant’s Date of Birth

Applicant’s Gender (circle one)
Male / Female / Uncertain /
Certain but not socially acceptable

Applicant’s Ethnicity (circle one)
White / Non-white /
Considered white when politically convenient

Reason for Application (check all that apply)
□ Old / Ancient
□ Bored / Restless
□ Virus / Bacteria / Fungus
□ Lapse of insurance
□ Fell down a well
□ Murderer in kitchen
□ Cop had a bad day
□ Quoth the raven
□ Other

Sign Below if You Agree with the Following Statement.
I, the undersigned, do understand that death is permanent and not reversible. I, the undersigned, am also not of sound mind and/or body.

Signature of Witness

Signature of Executor

Send completed form to:
Office of Gallows Humor
P.O. Box 000
Void, ZZ 00000-000


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