USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 22
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Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childhirth, 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 hest 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 seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 ond 1, os omended by Acts of 1910, Chop. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agenty. . . 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 onclerk, . . . 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 death, which the clerk or registrar may require. - Revised Laws, Chop. 78, Sec. 88.
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 deseription 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 hodies 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 disahled 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 by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
..................
(City or town)
1 PLACE OF DEATH
County.
north
Chelmsford
State
Registered No ..
57
Township
Chelmsford
City
No.
.......
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
Jameson Bennett
ton
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
Ward.
(Usual place of abode)
Lengt's 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
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year) Sept. 17, 1920.
7 AGE Years
Months
Days
If LESS than 1 day,.3 hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade; profession, or particular kind of work
(b) General nature of industry, business, or establishment in wbich employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
north Chelmsford
(State or country) mass.0
10 NAME OF FATHER Thomas Johnston.
11 BIRTHPLACE OF FATHER (eity or town)
Sarkhall
(State or country) Scotland
12 MAIDEN NAME OF MOTHER
annie maktmint /192 (Address)
13 BIRTHPLACE OF MOTHER (city or town). morning stile
(State or country) Scotland
14 Informant (Address) May, SN. /Kto Chetmsford
15
Filed Seft: 18, 1920 Odenard
REGISTRAR
16 DATE OF DEATH (month, day, and year)
Sufl- 17
1920
17 I HEREBY CERTIFY, That I attended deceased from Soft- 17 19 20
19
to.,
that I last saw hm
alive on
full- 17
,19
and that death occurred, on the date stated above, at
10-30 a.
m.
The CAUSE OF DEATH* was as follows :
Trematin birch
2
3 horas.
(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 ?
Date of ..
Was there an autopsy ?. ......
What test confirmed diagnosis ?
(Signed)
M.D.
nout Chluofen Didas
*'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
DATE OF BURIAL
19 0
20 UNDERTAKER
ADDRESS
.
.or
or Village
St.,
.......
.. Ward
(a) Residence. No ... 16 Gray St.
(If non-resident give city or town and State)
MEDICAL CERTIFICATE OF DEATH
MARGIN RESERVED FOR BINDING
PARENTS
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 of certificate.
68
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census 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," ctc., 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 discase. 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- ficd, 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 ncoplasms); 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 .; Broncho- pneumonia (secondary), 10 ds. Never report mcre symp- toms or terminal conditions, such as " Asthenia,"
"Col- "Anemia" (mcrely symptomatic), "Atrophy,' "Debility"" ("Con- lapse," "Coma," "Convulsions,"
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," 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- terminc 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. 10-'18. 5,000.
FORM R-301
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX male 6 DATE OF BIRTH (c) Name of employer (State or country) 10 NAME OF FATHER PARENTS 14 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 (b) General oature ofindustry, business, or establishment in which employed ( or employer ).
1 PLACE OF DEATH
County.
michelleset
State
Mass
Registered No. 58
City or Town
North Chelmsfacto.
Dunstable Band
St ...........
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
mes F Truben
If in the Army or Navy of the United States, give rank, organization, etc.)
No. Nast Chelombard
St.,-
.Ward.
(If non-resident give eity or towu and State)
Length of residence in city or towo where death occurred
50
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
nitrite
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
ann
Zruben
2/2 1841
(Day)
( Year)
7 AGE
79
Years
8/
Months
17
Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
.. mos.
If LESS than
1 day, ........ hrs.
or ........ min.
Cerebral Htemontage
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Retire
9 BIRTHPLACE (City)
Ireland
John Gruber
11 BIRTHPLACE OF
FATHER (City)
England
(State or country)
12 MAIDEN NAME
OF MOTHER
mary Weber
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
Qel.
9
1920
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Rune Liste North Chelimbach (Cemetery) (City or town)
DATE OF BURIAL
Cect 12
20 UNDERTAKER Jahn a Weinbach
ADDRESS Lawell was
Permit
Official position
Jon Cluck
Date of issue of permit
Oct. 12, 4 20No.
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
MEDICAL CERTIFICATE OF DEATH
Delobos
9
1920
16 DATE OF DEATH
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
Oct. 1
1920
to ..
Qal- 9
1928
that I last saw
b
alive on
Del. 9
20
19
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows :
( duration)
mos.
9
ds.
CONTRIBUTORY
High Blood Ocean
( SECONDARY)
(duration)
yrs.
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
200
Date of.
Was there an autopsy ?
200
What test confirmed diagnosis ? (Sigoed) Fred EVarney
M.D.
( Address )
north Chilcultural
Date
Informant
fam Trucker
(Address)
North Chelmetara
15 Oct. 12, 1920 Edward IRothman (Month) (Day) (Year)
REGISTRAR.
1-6-'19. 150,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
69
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1
(a) Residence.(
(Usual place of abode)
: Jan
( Month)
.yrs ...
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of oceupation 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, Compositar, Architect, Locamotive 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) Cotion mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factary. 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, Labarer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Hausekeepers who receive a definite salary), may be entered as Housewife, Hausework, 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, Caak, Hausemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSINO 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- braspinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Labar pneumania; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritaneum, etc., Carcinama, Sarcoma, etc., of .. .. (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whaaping cough; Chranic 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 ehildbirth or misearriage, 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.
XTRACTS
F 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 af 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, Scc. 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesier
State
Mars
Registered No.
59
St., ....... .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Infant Ducharme
(a) Residence.
No ..
R. H.2
Box 76
St.,
.Ward.
(If non-resident give city or town and State)
( Usual place of abode)
Length of residence in city or towa where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
Years
Months
Days
If LESS than 1 day, ........ brs. or ........ min.
If STILLBORN, enter that fact bere Still born
8 OCCUPATION OF DECEASED (a) Trade, profession, cr particular kind of work. (b) Name of employer
(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 ?. in Scorona
(Signed)
M.D.
(Address).
Date
Oct. 10
1920.
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
It Jarelay Chelamalar Oct 1 1920
(Cemetery)
(Cit
20 UNDERTAKER
albert
ADDRESS
171 aukey
Official position
Down Clock
Date of issue of permit Det, 13, 92 N ...
Permit
21 I HEREBY CERTIFY that a satisfactory stau- dard certificate of death was filed with me BEFORE the burial or transit permit was issned
Edward J. Pillows
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
Oct.
10
1920,
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
Oct. 10
19.20,10
Oct. 10.
19
20,
dead whin low
that Hast saw byl alive on
19
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows :
Still born
9 BIRTHPLACE (City)
Chelmsford
(State or country)
10 NAME OF
FATHER
Timothé Ducharme
11 BIRTHPLACE OF It esillaume
FATHER (City)
(State or country)
Convida
12 MAIDEN NAME
OF MOTHER
alma Bedarf
Mount Carmel
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
14 Timothé Durchaus
Informant
(Address)
Chelmsford
15
Det. 13, 1920 Edward & Robbing
(Month) (Day) (Year)
REGISTRAR
The Commonwealth of Massachusetts
70
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 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
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