(c) A certificate under this section shall be substantially in the following form:
(Convention of October 26, 1973)
I, __________________ (name, address, and capacity), a person authorized to act in connection with international wills, certify that on ________________________ (date) at__________________(place)___________________(testator)____________________(name, address, and date and place of birth) in my presence and that of the witnesses: _____________________ (name, address, and date and place of birth); and _____________________ (name, address, and date and place of birth) has declared that the attached document is the testator's will and that the testator knows the contents of the will.
I further certify that in my presence and in the presence 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 testator's will for the following reason ____________________, I have noted this declaration on the will and the signature has been affixed by _____________ (name and address);(3) the witnesses and I have signed the will;(4) each page of the will has been signed by _______________________ (name and address) and numbered;(5) I have satisfied myself as to the identity of the testator and of the witnesses as designated above;(6) the witnesses met the conditions requisite to act as such according to the law under which I am acting; and(7) the testator has requested me to include the following statement concerning the safekeeping of the testator's will: ____________________________________________________________________.
SIGNATURE _________________________________ and, if necessary, SEAL".