Section 1003. Certificate of dissolution; contents

(a) A certificate of dissolution, entitled "Certificate of dissolution
  of  .........  (name  of corporation) under section 1003 of the Business
  Corporation Law", shall be signed and delivered  to  the  department  of
  state. It shall set forth:
    (1) The name of the corporation and, if its name has been changed, the
  name under which it was formed.
    (2) The  date  its  certificate  of  incorporation  was  filed  by the
  department of state.
    (3) The name and address of each of its officers and directors.
    (4) That the corporation elects to dissolve.
    (5) The manner in which the dissolution was authorized.