USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 14
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Was there an autopsy ?
70 .
What test confirmed diagnosis ?.
(Signed) masa Howard. M.D.
(Address). Chelmsford, Mass
Date.
June
( Month)
(Day)
1919.
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Zdeon
DATE OF BURIAL
(Cemetery)
(City or town)
20 UNDERTAKER MundoBlater.
Lowsee
Official Patron Clerk 2: position.
Date of issue of or transit permit.
rial June 3,1919
10-'18. 100,000.
The Commomoralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
huddlesex
State. mais
Registered No.
City or Town.
Chelmsford
No.
Hough Jr
St.,
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Clarence E. Stevens
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ...
( Usual place of abode)
Length of residence in city of town where death occurred (-5
years
Chelamfad
St.,
Ward.
(If non-resident give city or town and State)
days.
How long io U. S., if of foreigo birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
mooths
207
42
ADDRESS
-
A.LU JIAIES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
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 enginecr, Civilengineer, 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 "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborcr, 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 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- 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," unqualified, 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,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Urcmia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth 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 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 MASSACHUSETTS 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 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 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 thercof 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 thereafter furnish 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 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.
MARGIN RESERVED FOR BINDING
3 SEX Female 7 AGE 83 particular kind of work. PARENTS carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. 15 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 (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH Desex
County ..
State ....
Mass
Registered No ..
113
Township
Chelmsford
.... or Village.
.or
City ... No.
St.,
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Halliwell
2 FULL NAME
(If ir. the Army of Navy of the United States, give rank, organization, etc.)
(a) Residence.
(Usual place of abode)
Length of residence in city or town where death occurred
4
years
months
days.
How long in U. S., if of foreign birth ?
47 years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
June 4 th
19/9
17
I HEREBY CERTIFY, That I attended deceased from
June 2
, 1919, to June 44
, 1919
that I last saw h .........._ alive on
, 1919.
and that death occurred, on the date stated above, at
.m.
The CAUSE OF DEATH* was as follows :
Heat Prostration
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
at Home
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) ..
England
10 NAME OF FATHER Im William
11 BIRTHPLACE OF FATHER (city or town) ...
(State or country)
Englund
12 MAIDEN NAME OF MOTHER Many OF
13 BIRTHPLACE OF MOTHER (city or town) Conalamot (State or country)
14 Harry Gillan
Informant,
(Address) Chelanthund Mars
Filed Same 6, 19/19 Edward &. Robbing
REGISTRAR
.(duration)
.
.. yrs ...
mos. ...
ds.
CONTRIBUTORY
Chronic
Cystitis
-
(SECONDARY)
.(duration)
4,
.... yrs ..
mos ..
ds.
18 Where was disease contracted
if not at place of death?
×
Did an operation precede death?
no. Date of
X
Was there an autopsy ?...
no
What test confirmed diagnosis ?
(Signed)
Amasa
Howard.
M.D.
DAM; 19/9 (Address)
Chelmsford, Man.
* 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
Odson Cemetery Lamell
DATE OF BURIAL June 1919
20 UNDERTAKER Atthogers
ADDRESS 445 yarkambia
1
(If non-resident give city or town and State)
4 COLOR OR RACE
Mente
5 SINGLE, MARRIED, WIDOWED, OR
-DIVORCED (write the word)
Widow
5a If married, widowed, or divorced -HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year)
Years
Months
Days
-
If LESS than 1 day, ......... hrs. or ........ min
.. St.,
... Ward.
)
208
.
2
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH : - 3 and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion 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, Compos- itor, 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 ma- terial worked on may form part of the second statement. Never return "Laborer," "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 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- 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 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 "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, 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 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "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 discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. 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 carbolic 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
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. 2-'18. 100,000.
FORM R-301
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
3 SEX
4 COLOR OR RACE
White
male
( Month)
7 AGE
70
Years
7
Months
14
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation.
... mos.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(c) Name of employer
9 BIRTHPLACE (City)
Liberty
( State or country)
FATHER (City).
PARENTS
Informant ..
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
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
(h) Generai nature of industry,
business, or establishment in
which employed ( or employer) ..
Farmer
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed.
5a If married, widowed, or diforced ,
HUSBAND of
(or) WIFE of
Elmira E Sanford
6 DATE OF BIRTH
Oct. - 21 -1848
(Day)
(Year)
Days
If LESS than
I day, ........ hrs.
or ........ min.
Retired.
maine
10 NAME OF
FATHER
Henry Sanford
11 BIRTHPLACE OF
Cannot be learned.
(State or country)
Cannot be learned
12 MAIDEN NAME
OF MOTHER
Cannot be learned
Cannot be learned.
13 BIRTHPLACE OF
MOTHER (City)
(State or country) 2 annof big learned
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH ..
(Month)
June
4
(Day)
1919.
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
1913 to.
. to Heure
Hur ych, 1919
that I last saw h we alive on
., 1919,
and that death occurred, on the date stated above, at ...
9 P. .... m. The CAUSE OF DEATH was as follows : anterio - Sclerosii
..... (duration)
10?
.yrs.
mos ...
ds.
CONTRIBUTORY
( SECONDARY)
C
(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 ?
200
What test confirmed diagopsis ?....
(Signed)
M.D.
( Address).
abril 1919
Date.
(Month )
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
edson
Lowell.
(Cemetery)
(City or town)
20 UNDERTAKER
George W.HEaley.
2 Official Down Clock 22 Date of issue of huria] position.
DATE OF BURIAL June 6 1919
ADDRESS 79 Branch Si
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued .. Edward. Robbins.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF
DEATH
FRISØR THE SECRETARY < DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County ..
Middlesent
State.
Massachusetts
Registered No.
44.209
Cityor Town
Chelemlord No.
Chelowford i Menaken St. Ward
(If-death occurred in a hospitalfor institution, give its NAME instead of street and number)
Luther Sanford
(If in the Army or Navy of the United States, give rank, organization, etc.)
Ghelsomford n. Manchan.
._ St.,
Ward.
(If non-resident give eity or town and State)
Length of residence in city or town where death occurred
15
years
months
days.
How long in U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
60
14 David Ingham
(Address ) Chelemford n. Manahan St
15
June 6, 1919 Edward & Rolling
(Month) (Day) (Year)
REGISTRAR
10-'18. 100,000.
Jane 6 1919
or transit permit.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
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 "Laborer," "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 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- 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 (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING NEATH (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," unqualified, 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,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth 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 by Com- mittec 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 MASSACHUSETTS 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 deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deccased, 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 scen 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 hercinafter 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 thereafter furnish 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. 1
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