HomeMy WebLinkAbout07-20-06 (2)
SP 4-031 (6-98)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Uniform Firearms Act, 18 PA. C.S. 6105 (c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or who has been involuntarily committed to
a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures Act of July 9, 1976 (P.L.817, No. 143) to possess, use,
manufacture, control, sell or transfer firearms. This would include adjudication of incapacity pursuant to 20 Pa.C.SA ~5501. Pursuant to the Pennsylvania Mental Health
Procedures Act, Section 109, notification shall be transmitted to the Pennsylvania State Police by the judge, mental health review officer or county mental health and mental
retardation administrator within SEVEN days of the adjudication, commitment or treatment by first class mail to the Pennsylvania State Police, Attention: Firearm Unit, 1800
Elmerton Avenue, Harrisburg, PA 17110. NOTE: The envelope shall be marked "CONFIDENTIAL."
Place an "X" on either involuntary Commitment or Adjudicated Incompetent
INVOLUNTARY COMMITMENT
ADJUDICATED INCOMPETENT X
Date of Involuntary Commitment or Adjudicated Incompetent
INDIVIDUAL INFORMATION (INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT)
LAST NAME: Drawbaugh
FIRST: Myrtle
MAIDEN NAME: Heilner
MIDDLE: A.
JR., ETC.
DATE OF BIRTH: 07/07/11
ALIAS:
SEX: F
RACE: Caucasian
SOCIAL SECURITY NUMBER: 204-03-6870
HEIGHT: 4' 9" WEIGHT: 100 Ibs. HAIR: White' cEYES: B.;c;_~n
ADDRESS: Manor Care, 1700 Market Street, Camp Hill, Pennsylvania 17011
County Submitting Notification
CUMBERLAND
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County Mental Health and Mental Retardation Administrator
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County Mental Health Review Officer
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act)
Hospital/Facility Providing TreatmenUAddress
Judge
SIGNATURE OF NOTIFYING OFFICIAL
DATE
Court Case Number
Date of Court Order
...........................................................................................
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the determination of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental
Health Procedures Act and pursuant to the Uniform Firearms Act, Section 6111.1 (g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through
the county mental health and mental retardation administrator or mental review officer.
Name of Physician (Please print.)
Signature of Physician
Date
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PRAECIPE/REQUEST In The Court of Common Pleas LJ 1"'0 6e filed with the Clerk of the
FOR ASSIGNMENT Cumberland County Pennsylvania Orpbans' ,Court
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INRE: ,
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MYRTLE A. DRAWBAUGH, an alleged incapacitated person
DOCKET # Estimated Hearing/Conference Time: Day(s) 1 Hour(s)
SPECIFIC MATTER TO BE ASSIGNED
(Check Only One Category)
Assianment Proceedinas and Conferences
Adoptions Compel Accounting Sale of Real Estate
InvoluntaryNoluntary Termination Objections to Account Attorneys Fees
X Guardian of Incapacitated Person Proceedings Against Fiduciaries Status Conference
Discharge Guardian Will Contest Argument
Guardian of Minor Inheritance Tax Appeal Other (describe)
Minor Settlement Terminate Trust
Wrongful Death/Survival Dissolution of Corporation/Charity
Name(s) and Judge(s) of related case(s)
Docket number(s) of related case(s)
Date: 7-/ f -O(r; ; l)fddt~
Attorney or Petitioner X Respondent
NAMES, ADDRESSES, E-MAILS & TELEPHONE NUMBERS OF ALL COUNSEL INVOLVED
(use back of form for additional names and addresses)
For the Petitioner(s): Telephone No.
Marielle F. Hazen, Esq. 717 -540-4332
For the Respondent(s): Telephone No.