USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 21
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under the head of "Contributory." (Recommendations on statement of cause of deatlı 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, ctc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ctc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
FORM R-301
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
The Commomuralth of Massachusetts
226
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH' County ..
State
Mass
Registered No ....
City or Town.
Chelmsford
No
actri
St
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Clorinda It Zarchest.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. Novbeter di
(Usual place of abode)
St.,.
Ward.
(If non-resident give city or town and State)
Length of resideoce io city or town where death occurred
86. se
months
days.
How long in U. S., if of foreign hirth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Semale Aheti
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Vidm
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Derne Gi Gaucheist.
6 DATE OF BIRTH
( Month)*
24 1933
(Day)
(Year)
7 AGE
86
Years
Months 1Days
If STILLBORN, enter that fact here If STILLBORN, state period of uterogestation mos.
1 day, ........ hrs. or ........ min.
If LESS than The CAUSE OF DEATH was as follows : Arterio soberania - Senility-
Serral
( duration)
yrs.
mos ...
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 Auchun T. Scoloria
(Signed)
M.D.,
(Address).
Cebulaford,
mars.
Date.
(Month)
(Day)
1919.
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Paul athu
Chelmotal
(Cemetery)
(City or town)
DATE OF BURIAL Lug. 13 1919.
15
amy 13, 1919 Edward Rettung
(Month) /(Day) (Year)
REGISTRAR
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 ) . Rottung
Official position.
Com clube
22 Date of issue of burial or transit permit
aug 3, 99
10-'18. 100,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
(Day)
(Year)
17 HEREBY CERTIFY, That I attended deceased from Jan.
1919, to/
aug/1, 1919.
that I last saw h Ry alive on
July 28, 1919.
and that death occurred, on the date stated above, at.
m.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (h) Geoeral nature of industry, business, or establishment in which employed ( or employer) ..
(c) Name of employer
Chelmsford
9 BIRTHPLACE (City)
(State or country)
Mass.
PARENTS
11 BIRTHPLACE OF FATHER (City ). (State or country)
Massachusetts
12 MAIDEN NAME
OF MOTHER
Sarah Spaulding
13 BIRTHPLACE OF MOTHER (City) (State or country)
14 Otrathirty Parkhurst
Informant (Address) Chelasford Mars
ADDRESS
20 UNDERTAKER William It Daunder fortell. Mars.
STANDARD CERTIFICATE OF DEATH
MARGIN RESERVED FOR BINDING
4 COLOR OR RACE
1919
10 NAME OF
FATHER
Usa Hodgman
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
hy U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupatien 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. Butin 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 mere 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. Carc 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 fevcr (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- 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 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 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 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 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 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 deatlı, 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 persens 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
1919 85-
183 4-
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See 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.
The Commmuralth of Massachusetts
227
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Middlegen
State. Mars,
Registered No. .......
City or. Town ..
Chelmsford
.No.
Chelmsford
St.,.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Charles , Adame.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No
Chelmsford
St.
Ward.
(If non-resident give city or town and State)
Length of resideoce in city or towo where death occorred
6
years
months
days.
How loog io U. S., if of foreign hirth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Maler
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed.
5a If married, widowed pr divorced
HUSBAND of
(or) WIFE of
Vivian Brown
6 DATE OF BIRTH
April
(Month)
15.
(Day)
(Year)
7 AGE 85 Years 4 Months 3 Days
If STILLBORN, enter that fact here If STILLBORN, state period of otcrogestatioo mos.
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work.
(h) Genera; nature of industry,
business, or establishment in
which employed ( or employer).
Retired.
(c) Name of employer
9 BIRTHPLACE (City)
Carlisle.
(State or country)
Nace.
10 NAME OF
FATHER
Benjamin S. Adamo!
PARENTS
11 BIRTHPLACE OF
FATHER (City)
Carlisle.
(State or country)
Mare.
12 MAIDEN NAME
OF MOTHER
Ali Heald.
Carlisle
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Macer.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
Aug
18.
(Month)Y
(Day)
1919
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
aug. 6
1919, to aug.18
1919 ..
that I last saw h ... alive on
aug. 13
, 1919.
and that death occurred, on the date stated above, at ..
40 ...... m. The CAUSE OF DEATH was as follows : Carbral Embolism
(duration)
yrs ...
mos /2 ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.. yrs
.. mos ..
ds.
18 Where was disease contracted
if not at place of death?
X
Did an operation precede death? no.
Date of ..
Was there an autopsy ?
What test confirmed diagnosis ?.
(Signed)
Amasa
howard M.D.
(Address) ..
ichelmsford Mars
Date ..
Assis.
180
1919.
(Year) /
( Month)
(Day)
14
Informant Mora Catherine Mr Smith
(Address)
Cheemaford Center, Mace.
15
guy 19, 1919 Edward . Rotting
(Monthy (Day) (Year)
REGISTRAR
19 PLACE OF BURIAL, CREMAIJON, OR REMOVAL
Greene, Garlicle, Mass.
Cemetery)
(City'or-town)
DATE OF BURIAL
Aug, 20. 19 / 9 .
20 UNDERTAKER
GromHealey,
ADDRESS
Lowell, Mass.
21 1 HEREBY CERTIFY that a satisfactory stan- dard certificate of death was Gled with me BEFORE the burial or transit permit was issued
Edward S. Rot Ling
ficial Town Clerk
22 Date of issue of burial or transit permit.
aug. 17, 1919
MARGIN RESERVED FOR BINDING
10-'18. 100,000.
STANDARD CERTIFICATE OF DEATH
2 FULL NAME
( Usual place of abode)
1834.
Retired.
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, 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 sccond 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 he 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 NEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. 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 he 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 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 discase 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. - 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 hy 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 practicc:
(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
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See 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. should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF/DEATH
228 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
madlarx
> mass
Registered No.
City or Town ...
Culuund
No 997, Trueyou
St. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
William Nincs
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
994 trincelon
St.,. Ward.
(If non-resident give city or town and State)
( Usual place of abode)
Length of residence ia 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
3 SEX
male white
4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OB DIVORCED (write the word)
manica
5a If married, widowed, or divorced HUSBAND of (or) WIFE of of Mary Curran
6 DATE OF BIRTH.
July 4 1879 Day)
(Year)
7 AGE
40
Years
Months
Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation.
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work .. (h) Generai nature of industry, bosiness, or establishment in which employed ( er employer) le
Halid
.... mos. bill
(c) Name of employer Silesia mille
9 BIRTHPLACE (City)
(State or country)
mass
PARENTS
10 NAME OF
FATHER
Malachi Hus
11 BIRTHPLACE OF
FATHER (City) ..
Lowell
(State or country)
mass
12 MAIDEN NAME
OF MOTHER
inmis Quarters
, 13 BIRTHPLACE OF MOTHER (City) (State or country) Dicland ...
14 Mary Cuman Sales 's Informan (Address)
15
Filed aug. 22, 1919 Edward &. Robbing
(Month) (Day) (Year)
REGISTRAR
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 J. Robban
Official Town Check . position .....
Date of issue of permit Quy. 229,19 No
Permit
1-6-'19. 150,000.
16 DATE OF DEATH Lug 20 1219 ( Mouthy
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from aug 20 1919, to Buy 20, 1919, that I last saw him alive on Quy 20, 1919, and that death occurred, on the date stated above, at ............... cis m. The CAUSE OF DEATH was as follows :
1.
f ..... (duration)
.. yrs ...
mos ...
.ds.
CONTRIBUTORY.
(SECONDARY)
.(duration)
.yrs ..............
.. mos ...
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