§ 64-2-437

The authorized person shall attach to the will a certificate to be signed by him establishing that the requirements of this article for valid execution of an international will have been complied with. 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:\nCERTIFICATE\n(Convention of October 26, 1973)\nI,................… (name, address and capacity), a person authorized\nto act in connection with international wills\nCertify that on..............…(date)............… (place)\n(testator)........................… (name, address, date and place of\nbirth)in my presence and that of the witnesses\n(a)..........................… (name, address, date and place of\nbirth)\n(b)..........................… (name, address, date and place of\nbirth)\nhas declared that the attached document is his will and that he knows\nthe contents thereof.\nI furthermore certify that:\n(a) in my presence and in that of the witnesses\n(1) the testator has signed the will or has acknowledged his\nsignature previously affixed.\n*(2) following a declaration of the testator stating that he was\nunable to sign

in that of the witnesses\n(1) the testator has signed the will or has acknowledged his\nsignature previously affixed.\n*(2) following a declaration of the testator stating that he was\nunable to sign his will for the following reason\n..........................… I have mentioned this declaration\non the will\n*and the signature has been affixed by (name and address)\n(b) the witnesses and I have signed the will;\n*(c) each page of the will has been signed by\n..........................… and numbered;\n(d) I have satisfied myself as to the identity of the testator and of\nthe witnesses as designated above;\n(e) the witnesses met the conditions requisite to act as such\naccording to the law under which I am acting;\n(f) the testator has requested me to include the following statement\nconcerning the safekeeping of his will:\nPLACE OF EXECUTION\nDATE\nSIGNATURE and, if necessary, SEAL.\n* to be completed if appropriate\n1995, c. 443, § 64.1-96.6; 2012, c. 614.