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 |