HomeMy WebLinkAbout06-18-09 P 4-131 (3-2009) COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
In accordance with 18 Pa. C.S. 6111.1(fl(1)(i), judges of the courts of common pleas shall notify the Pennsylvania State Police (PSP) of the identity of
any individual who has bee 6aP L ~$1~dNo. 143) knownt ans theaMentaeHealth Procedures Act,aorbwho has beenrlinvo~untarilytreated astdescribed in
under the act of July 9, 197
section 6105(c)(4) (relating to'isemolementi g Federal regulationsUfTh srnot ficatioln shal~bertransemi ted by the judge to the PSP w8h n SEVEN2days(of
(relating to unlawful acts) and p
the adjudication, commitment, or treatment, at the address below.
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 w o
has been involuntarily comm~teNo. 143) to possess ~use,r manu'facturee control asell or Vansferefirearms?This would include adj dicationt oPincapac ty
Act of July 9, 1976 (P.L. 61 ,
pursuant to 20 Pa.C.S.A. 5501. Pwsoffcer~ ohe ountyymentalrhealth andltmentae eta datfon adm'~ni tr0ator~wthintlSEVEN days ofntheeadjudicaton,
by the judge, mental health revie
commitment or treatment by first cliso be forwardedeto the sheriff of the clounty n wh ch this person resides neacco dance with 18 Pa C.S §
17110. A copy of this form must a 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 I~m~petent ~ r
~G L„ i - ~
PRINT CLEARLY OR TYPE ^302^303^304 OTHER ~~~ ~ ,`: i
rn
~ `~
ADJUDICATED INCOMPETENT ~c;; ?
INVOLUNTARY COMMITMENT ^ ^ ^ ^ '~--?~~, c ~~ --~
06/15/2009 ~ ~ -j,
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT ;~
_ ~ ~ ': Tx
Cumberland ,~ ~ .
COUNTY OF COMMITMENT .~
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCLMP~ENT
Bonarrigo FIRST Thelma MIDDLE
LAST NAME
Barry ALIAS
JR., ETC. ~-MAIDEN NAME 208181515
DATE OF BIRTH 12/13/1927 SOCIAL SECURITY NUMBER GREEN
(Optional, but will help prevent misid122fication) HAIR GRAY EYES
SEX F RACE C HEIGHT 5 ' 4_ WEIGHT __- --
ADDRESS 609 HILLTOP DRIVE NEW CUMBERLAND PA 17070
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involu~nneryn oommeamenAt t) Please Print Name and Provide Signature
(Required in accordance with Section 6105(c)( )
Hospital I Facility Providing Treatment I Address
~~~~~~~~~~~~~~~~~"•••^••~^^•••••••^••^^••^•e andtele hone number of agency or county court)••••••••'
NOTIFICATION BY (Please print name, address, area cod p 717 240 6345
Telephone
MH1MR Administrator/Review Officer
303-304 Commitment requires the JudgelP.evievd Officer name authorizing the commitment, case number, & order date
JudgelReview Officer KEVIN A HESS JUDGE
06115/2009
21-09-0448 Date of Court Order
Court Case Number
Date ~~`~^~ ~~ ~~
SIGNATURE OF NOTIFYING OFFICIAL
NOTIFICATION OF PHYSICIAN'S DETERMIN~, ION THAT NO SEVERE MENTAL DISABILITY EXISTS
~ ~ ~ ^ • • • ^ ^ ^ ^ ^ ^ • ^ • • ^ • ^ ^ion of the lack of severe mental disability following the initial•examination under Section 302(b) of the
3 Notice shall be transmitted by physician
The physician shall provide signed confirmat
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(
to the Pennsylvania State Police through the county Mental Health and Mental Retardation Administrator or Mental Health Review Officer.
Name -Physician (Please print.)
Date
Signature -Physician
PRIVACY ACT NOTICE: Solicitation your octal security u berrz f pro ~dedl tmay be used to verity your idl entity an preventomisid'entYication.
your social security number is voluntary
All information supplied, including your social security number, is confidential and not subject to public disc osure.
Original: Pennsylvania State Police
r~nnv County Sheriff's Office (see web site: www pasheriffs.orq for current sheriff information