HomeMy WebLinkAbout08-29-08 P 4131(5-2006)
COMMONWEALTH 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, 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.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. A Dopy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with 18 Pa.C.S. § 6109(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS."
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incompetent
;~^.~
PRINT CLEARLY oR TYPE 302 303 304 OTHER c~ `a
,~ ~ i~ -
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPET1~-,D ~, -
s 27 Zoos
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT / / ~ ~' ~
1 .--.
~,..
COUNTY OF COMMITMENT CUMBERLAND - -~
hi ~ -,
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATEl~'INCOMPEfT~NT
-..i
LAST NAME GALLAGHER
JR., ETC. MAIDEN NAME
DATE OF BIRTH 11 / 23 / 1926
SEX Male RACE CAU HEIGHT 5 ' 6 WEIGHT 122.8 HAIR WHITE EYES BLUE
ADDRESS FOREST PARK NURSING HOME 700 WALNUT BOTTOM ROAD CARLISLE PA 17013
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act)
Hospital /Facility Providing Treatment /Address
Please Print Name and Provide Signature
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Telephone 717-240-6345
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer JUDGE KEVIN A HESS
Court Case Number 21-08-0788
Date of Court Order 8 / 27 / 2008
SIGNATURE OF NOTIFYING OFFICIAL ~~~~ ~~'"^ Date ~~ lC~°~ l a~y ~1
NOTIFICATION OF PHYSICIAN'S DETERMINATIQN THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of vere 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 ental Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
FIRST WILLIAM
MIDDLE JAMES
ALIAS
SOCIAL SECURITY NUMBER 578-30-0253
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.pasheriffs.ors for current sheriff information)