USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 11
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State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACriu GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or otlier authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or .. . from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, .. . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . . . The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Reviscd Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
FORM R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
118
· OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH dekers
County ..
City or Town
Checonsfact
No ..
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Catherine Bell, Mac naughton
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Hast Chelmsfall.
St.,
Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred 20
years
months
days.
How long in U. S., if of foreign birth? 46
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
ghita
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of MaTheur Mac Naughton
6 DATE OF BIRTH
March 24,
( Month)
(Day)
(Year)
7 AGE
49
Years
/
Months
Days
If LESS than
1 day, ........ hrs.
or ........ min.
at home
9 BIRTHPLACE (City) :.
(State or country)
Scotland
FATHER
Hugh Bell
11 BIRTHPLACE OF
FATHER (City).
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Isabell, Gardner
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
14 MirThere Mac naughton
(Address )
Siget Chelmlad Mann
15
afval 26 1919 Edward Rottung
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
17
HEREBY CERTIFY, That I attended deceased from
September
, 19/8, to
, 1919
that I last saw her.
alive on
apres S.4, 19%%.
and that death occurred, on the date stated above, at .....
t 2.18 Pm.
The CAUSE OF DEATH was as follows :
Cancer of the
I the lung
CONTRIBUTORY.
Cancer the head,
..... ( duration)
0 yrs
.ds.
( SECONDARY)
sure Je
(duration)
yrs
mos .......
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ? Removed 7 hearts ghase
Was there an autopsy ?
about one year ago
What test confirmed diagnosis ?..
Fred Wam
neyo.
(Signed)
M.D.
(Address).
28
1914
Date
( Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Hast Chelmsford Mars
(Cemetery) .
(City or town)
DATE OF BURIAL april 27 1919
ADDRESS
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward J. Rolling ........ position
Official com Click
22 Date of issue of burial alin 26/9/19 or transit permit
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
10-'18. 100,000.
(Usual place of abode)
3 SEX
Famala
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(h) General nature ofindustry,
business, or establishment in
which employed (or employer).
(c) Name of employer
10 NAME OF
PARENTS
Informant.
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
If STILLBORN, state period of nterogestation.
mos.
1870
april
24
1919
(Day)
(Year)
State.
Massachusetts,
.. Registered No ...
33
20 UNDERTAKER David & Privat son
7
1.
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. , For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Lahorer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may he entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should he taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualificd, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .. .... (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma,""Convulsions,""Dehility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can he ascertaincd as the cause. Always qualify all discases resulting from childhirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved hy Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS
COMMON
FROM THE LAWS OF THE ALTH OF MASSA
*TS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deccased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1. as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall hury a human body . . . until he has received a permit from the hoard of health or its agent, . . . or ... from the clerk of the city or town in which the person dicd; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall he accompanied hy a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . . . The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may he, with the cause and manner of his death, and shall make examination upon the view of the dead hodies of only such persons as are supposed to have come to their death hy violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the ohservance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given hedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly hy traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, hut also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14
Informant
James Hutwelt
(Address)
15 Filed. apr. 30, 1919 Edward &. Bobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Jeril 29 2019
17
I HEREBY CERTIFY, That I attended deceased from
Dec 27, 1918 to Dec 25
, 1918
that I last saw ha alive on
..........
Des 28, 1918.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
(duration)
yrs .....
mos ..
ds.
CONTRIBUTORY Lerdecanet
(SECONDARY)
.(duration) ... yrs ...
mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?.
.Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?.
(Signed)
M.D.
/29.1918 (Andress) му А рами
* State the DISEASE CAUSING DEATHI, or in deaths from VIOLENT CAUSES, statc (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (Sec reverse side for additional spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL~
DATE OF BURIAL Thewater Levelig May/ 1919
20 UNDERTAKER
ADDRESS ech ye hudidleun
....
St.,.
Ward
(If dcath occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
mary Am Hocking
(a) Residence. No .....
(Usual place of abodc)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
15
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female While
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year) and 241862
7 AGE
Ycars
5.6
Months
10
Days
1
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
denne Marte
(b) General nature of industry, business, or establishment in which employed (or employer) . (c) Name of employer
James & Butwell
BIRTHPLACE (city or to
(State or country)
0 renglon of
PARENTS
10 NAME OF FATHER eehh Havetime
11 BIRTHPLACE OF FATHER (city or town) (State or country) England
12 MAIDEN NAME OF MOTHER hit Lerin
13 BIRTHPLACE OF MOTHER (city or toum). (State or country) Enplaner
199
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH ....
(City or town)
1 PLACE OF DEATH
County ...
State
Registered No. 34
Township ......
... or Village.
or
City.
St.,
, ................ Ward.
(If non-resident give city or town and Statc)
MARGIN RESERVED FOR BINDING
3
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
'Approved by U. S. Census and American Public Ilealth Associatiou]
"ation. - Precise + of occupa-
tiol. so that the rela.
Various pursuits van ve shown. The queseva appunto each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifieally the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). . For persons who have no occupation whatever, write None.
Statement of cause of death .-- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, ete., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by earbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recomm ns on statement of cause of death approved by C ee on Nomenclature of the American Medical As .)
Cases for the Medical Examiners. - Under tl
sions of chapter 24 of the Revised Laws deaths u
unuwing conditions must be referred to the meurval Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homieide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX Female 7 AGE PARENTS 14 (Address) of certificate. so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
Informant
F.W. Derbyshire
15 Filed. Many 2.2019 Edward , Rolling REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) May 1, 1919.
17 I HEREBY CERTIFY, That I attended deceased from apr. 19 , 1919, to May 1, 1914
that I last saw h M alive on
apr. 30 1919.
2a
and that death occurred, on the date stated above, at
.......... m.
The CAUSE OF DEATH* was as follows:
Broncho pneusnowa'
/
tremaril
.(duration)
......... yrs ....... Chos 9 ds.
CONTRIBUTORY.
(SECONDARY)
.... (duration)
yrs ..
.. mos ..
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? NO, Date of
....
Was there an autopsy ?.
no.
What test confirmed diagnosis ?
Antenne 9. Scolonia
M.D.
(Signed)
5-2. 19/9 (Address)
chacuneford, max.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES. state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Lowell Com. Lowell.
20 UNDERTAKER Walter Perham
DATE OF BURIAL May 3 1919
....
or Village.
No.
St., .......... ... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) ... , ....
City
Lizzie Conant
Nagie.
want Derbyshire
....... (Ifix the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
steadman St.
St.,
... Ward.
.......
(Usual place of abodc)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
Frederick W. Derbyshire
6 DATE OF BIRTH (month, day, and year) may 111, 1871
Years
Months
48
/
Days
20
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
Housewife
9 BIRTHPLACE (city or town).S.
(State or country)
10 NAME OF FATHER Shutt Conant
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER Mary Butcher
13 BIRTHPLACE OF MOTHER (city or town) not Known (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
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