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.

    99/102 (page 99)
    APPENDIX. FORMS CONCERNING ADMISSION TO THE HOSPITAL. PETITION. [The applicant must answer in writing the printed interrogations accompanying this blank.] I To the Honorable the Judge of the Probate Court, in and for the County of of on oath complains that of , in said county of , is an insane person, and a proper subject for the treatment and custody of the Worcester Lunatic Hospital. Wherefore, h prays that said may be committed to the said Worcester Lunatic Hospital according to law. , ss. A. D. 186 . Then the above named made oath that the above complaint, by h subscribed, is true. Before me, Justice of the Peace. I, the subscriber, one of the selectmen of where said resides, hereby acknowledge that notice has been given to me of the intention to present the foregoing complaint and application. A. D.186 . To the Honorable the Judge of the Probate Court, in and for the County °f m • The subscriber, having made application to your Honor for the commitment of to the Worcester Lunatic Hospital, as a lunatic, now presents the following statement, in answer to interrogatories :— What is the age of the lunatic ? Ans. Birthplace ? Ans. Civil condition of lunatic ? Ans. Occupation ? Ans. Supposed cause of disease ? Ans. Duration ? Ans. Character—whether mild, violent or dangerous ? Ans.