(5) The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of this section for valid execution of an international will have been fulfilled. The authorized person shall keep a copy of the certificate and deliver another to the testator. The certificate must be substantially in the following form: ______________________________________________________________________________
CERTIFICATE
(Convention of October 26, 1973)
1. I, _________ (name, address and capacity), a person authorized to act in connection with international wills,2. certify that on _________ (date) at _________ (place)3. (testator) _________ (name, address, date and place of birth) in my presence and that of the witnesses4.(a) _________ (name, address, date and place of birth) (b) _________ (name, address, date and place of birth) has declared that the attached document is the will of the testator and that the testator knows the contents thereof.5. I furthermore certify that:6.(a) in my presence and in that of the witnesses (1) the testator has signed the will or has acknowledged the testator's signature previously affixed.(2)* following a declaration of the testator stating that the testator was unable to sign the will for the following reason ____________, I have mentioned this declaration on the will, *and the signature has been affixed by _________ (name and address)7.(b) the witnesses and I have signed the will;8.(c) * each page of the will has been signed by ________ and numbered;9.(d) I have satisfied myself as to the identity of the testator and of the witnesses as designated above;10.(e) the witnesses met the conditions requisite to act as such according to the law under which I am acting;11.(f)* the testator has requested me to include the following statement concerning the safekeeping of the will: _______________14. SIGNATURE and, if necessary, SEAL *to be completed if appropriate
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