The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of this chapter 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 shall 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 witnesses

4.(a) _____ (name, address, date and place of birth) _____

(b) _____ (name, address, date and place of birth) _____

has declared that the attached document is his will and that he 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 his signature   previously affixed.

(2)following a declaration of the testator stating that he was unable    to sign his 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 his will:*

12.

PLACE OF EXECUTION

13.

DATE

14.

SIGNATURE and, if

necessary, SEAL

__________

*to be completed if appropriate

(Enacted by Stats. 1990, Ch. 79.)