Form C. STATE OF MAINE. CERTIFICATE OF DEATH Name, 1st twins Place of Death, Tremini No. Street. Ward, Village, How long a resident, Previous residence, Date of Death: Year, 1917Month, 2 Day 2 Age: Years, Months, Days, 1/ Place of Birth, summent 2 Date of Birth: Year, 191/ Month. 2 Day, / Married, Single, Sex, m Color, w Widowed, or Divorced. 1 Occupation, Name of Father, Maiden Name of Mother, Burdell m Pormany Birthplace of Mother, Premant me Birthplace of Father, Day in me. Occupation of Father, Cook Deceased was wife of Widow of 1 111 [Over]