HomeMy WebLinkAbout06-18-08 (2) OMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania 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, 1979 (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_S.A. 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: PICS Unit, 1800 Elmerton Avenue,
Harrisburg, PA 17110. NOTE: The envelope shalt be marked "CONFIDENTIAL."
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE 302 303 3oa OTHER:
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT Cumberland County
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Stone FIRST Bertha MIDDLE E
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 11/17/1906 SOCIAL SECURITY NUMBER 174-05-1984
SEX FM RACE ~ HE{GHT ,~ ~ WEIGHT ~ ~ ~ l~-S HAIR c~ (~ t~~, EYES N 2 L.c,~
ADDRESS Church of God Home, Inc., 801 North Hanover Street,
Carlisle, PA 17103
302 Commitment Requires Physician's Certification
~-.~
Physician Certifying Necessity of involuntary Commitment nO
(Required in accordance with Section 6105(c}(4) of the Uniform Firearms Act} ~' ~- `
~--~ ~~
Please Print Name and Provlc~~ ~ natur€~= _ ;
-..,
a ; ;~ ~ f .
_ v'~ ..~
Hospital l Facility Providing Treatment (Address - _
NOTIFICATION BY (Please print name, address, area code, and phone number of agenc~~ countq.~our~) ' ;-
MH/MR Administrator /Review Officer Phone ~ 71 7) 2 ~ - 6 3 4 5
Address Cumberland County Clerk of Orphans' Court, Cumberland County
Courthouse, One Courthouse Square, Carlisle, PA 17013
303 and 304 Commitment -Requires Judge's name authorizing commitment, case number 8~ order date
Judge
Court Case Number to of Court Order
SIGNATURE OF NOTIFYING OFFICIAL
_ Date ___.
J ~~- ~ C L
Z~
NOTII=(CATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY
EXISTS
The physician shall provide signed confrmation 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 Pennsylvania Uniform Firearms Act, Section 6111.1 (g}(3). Notice shall be transmitted by physician to the
Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer.
Name of Physician (Please print.)
Signature of Physician Date
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
In Re: BERTHA STONE,
AN ALLEGED INCAPACITATED PERSON CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-08-0173
CERTIFICATE OF SERVICE OF ORDER
ORDER DATE:
JUDGE'S INITIALS:
TIME STAMP DATE: 06/18/08
IN Rl:i: NOTIFICATION OF MENTAL HEALTH COMMITMENT
SERVICE TO: SHERIFF OFFICE OF CUMBERLAND COUNTY
METHOD OF MAILING:
^ USPS
^ RRR
(~ HAND DELIVERED
[] OTHER
MATLED: 06/18/08
ENVELOPES PROVIDED BY:
^ PETITIONER
^ JUDGE
^ CLERK OF ORPHANS COURT
SERVICE TO: PA STATE POLICE
METHOD OF MAILING:
® USPS
^ RRR
^ HAND DELIVERED
^ OTHER
MAILED: 06/ 18/08
ENVELOPES PROVIDED BY:
^ PETITIONER
^ JUDGE
® CLERK OF ORPHANS COURT
Deputy 1
Clerk of Orphans' Court