§ 18-705. International will; certificate.

"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 or her 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) [to be completed if appropriate] following a declaration of the testator stating that he or she 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) [to be completed if appropriate] 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) [to be completed if appropriate] 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."