Form C. STATE OF MAINE. CERTIFICATE OF DEATH No. of Record, Name, Fud 73 Jackson Place of Death, Premoid Street, No Ward Date of Death : Year 1913 Month, 5 Day, 5 Age : Years 28 Months, 11 Days. Place of Birth, Plain Jampera Sex M Color, Mr Married, Single, Widowed,or Occupation, mushaux Divorced. Name of Father, Thomas Jackson Maiden Name of Mother Birthplace of Father, of Mother, Premoid Birthplace Occupation of Father, Merchant Deceased was wife of Widow of [OVER]