CERTIFICATE
(Convention of October 26, 1973)

 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

 (1)the testator has signed the will or has acknowledged his signature
  previously affixed.

 (2)following a declaration of the testator stating that he 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)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)  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

__________

*to be completed if appropriate