Form C. STATE OF MAINE. CERTIFICATE OF DEATH Name, 29 Twin Place of Death, Trement No. Street. Ward, Village, How long a resident, Previous residence, Date of Death: Year, 1417Month, 2 Day, 5 Age: Years, Months, Days, 4 Place of Birth, Trement Date of Birth: Year, 1917 Month, 2 Day, / Married, Single, Sex, m Color, w Widowed, or Divorced. Occupation, Name of Father, Henry A groduin Maiden Name of Mother, Burdell In Pannoy Birthplace of Father, D any In me. Birthplace of Mother, Treasunt Occupation of Father, Cook Deceased was wife of Widow of 1 [Over]