Form C. STATE OF MAINE. CERTIFICATE OF DEATH Name, Hiram a Do ix Place of Death, Bernard, maine No. Street. Ward, Village, How long a resident, Life Previous residence, Date of Death: Year, 1917 Month, aug Day, 16 Age: Years, 84 Months, 10 Days, 16 Place of Birth, west Tremont, me Date of Birth: Year, 1832 Month, Sept Day, 30. Sex, male Color, white Married, Single Widowed, or widowed Divorced. Occupation, Sea captain (mariner) Name of Father, John Dix. Maiden Name of Mother, Apphia Bartlette Birthplace of Father, West Tremont, me Birthplace of Mother, Bartlette Island Occupation of Father, Mariner Deceased was wife of, Widow of Emily Dix. [Over]