72-2-905. Certificate. The authorized person shall attach to the will a certificate to be signed by the authorized person establishing that the requirements of this part 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)

I, ______________ (name, address, and capacity), a person authorized to act in connection with international wills, certify that on _________ (date) at ____________ (place) (testator) _________________ (name, address, date, and place of birth) in my presence and that of the witnesses

(a) ______________ (name, address, date, and place of birth)

(b) ______________ (name, address, 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 furthermore certify that:

(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);

(b) the witnesses and I have signed the will;

*(c) each page of the will has been signed by _____________ and numbered;

(d) I have satisfied myself as to the identity of the testator and of the witnesses as designated above;

(e) the witnesses met the conditions requisite to act as such according to the law under which I am acting;

*(f) the testator has requested me to include the following statement concerning the safekeeping of the will:

* to be completed if appropriate