Thirty-fifth annual report of the trustees of the State Lunatic Hospital at Worcester. October, 1867.

  • State Lunatic Hospital at Worcester.
Date:
1868
Catalogue details

Licence: Public Domain Mark

Credit: Thirty-fifth annual report of the trustees of the State Lunatic Hospital at Worcester. October, 1867. Source: Wellcome Collection.

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    Homicidal or suicidal ? Ans. Paralytic or epileptic ? Ans. Previous existence of insanity in the lunatic ? Ans. Previous or present insanity in any of the family ? Ans. Habits in regard to temperance ? Ans. Whether he has been in any lunatic hospital; if so, what one, when, and how long ? Ans. (If a woman.) Has she ever borne any children ? Ans. (If a woman.) How long since the birth of her last child ? Ans. Name and post-office address of some of the nearest relatives or friends ? Ans. What facts show whether h has or has not a settlement, and where, if anywhere, in this State ? Ans. [For the law relating to settlement, see Gen. Stat., chap. 69.] Applicant. PHYSICIANS’ CERTIFICATE. The subscribers, respectable physicians of in the county of , having made due inquiry and personal examination of named in the foregoing application, within one week prior to the date hereof, certify that the said is insane, and a proper subject for the treatment and custody of the Worcester Lunatic Hospital. A. D. 186 . , ss. A. D. 186 . Then the above named and made oath that the above certificate is true. Justice of the Peace. for the commitment in said county, to the Worcester ; notice in writing having been Commonwealth of Massachusetts. ss. At , in said county on the day of A. D. 186 . On the application of of of Lunatic Hospital, given by said applicant to one of the selectmen of where said resides, of h intention to make said application, and said having been duly notified of the time and place appointed for hearing, it appears, upon a full hearing, that said is an insane person, and a proper subject for the treatment and custody of the Worcester Lunatic Hospital. Wherefore it is ordered that said be committed to the said Worcester Lunatic Hospital. Judge of Probate Coui't.