HomeMy WebLinkAbout09-09-09 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Po.C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or
who ha'4 been involuntadly committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health
Proced res act of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would inGUde adjudication of
incepa tY pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures AG, Section 109, notification shall be transmitted
to the P nnsylvania State Police by the judge, mental health review officer, or county mental health and mental retardation administrator in SEVEN
days of the adjudication, commitment or treatment by fret Gass mail to the Pennsylvania State Police, Attention: Unit, 160~merton
Avenu Narrtsburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the eoun hlch t perspn =r,:
reside in accordance with 18 Pa.C.S. § 6108(1.1 )(2). The envelope should be marked "CONFIDENTIAL -A ~ ~
FlREAR~, n ~ .
Plaee an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adludlcated In ~ ~t ~ ~, ~
Gib 't')
~C`> ~ ~ ~', ~ YJ
PRINThCL_EARLY OR TYPE 302 303 304 OTHER c->oQ ~ ~-~ ~.~
O
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPE~1~`T ^/ x '''~, ~
w ~
;:,~ , r~t
DATE F COMMITMENT OR ADJUDICATED INCOMPETENT s / 3 /2009 W ~ ~ ~ - -
COUNTY OF COMMITMENT Cumberland
INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Syphax
JR.,E
DATE
SEX
302
MAIDEN NAME
BIRTH 5 ~ 30 ~ 1932
FIRST Theodore
ALIAS
SOCIAL SECURITY NUMBER 180-24.7075
MIDDLE
a.m.,,nman~„
RACE HEIGHT ' 74 WEIGHT 214 HAIR Brown
46 Ertord Road, Camp Hill PA 17011
fitment Requires Physician's Certification
EYES Brown
Phyaicia~ Certifying Necessity of Involuntary Commitment
(Requir tl in accordance with Section 6105(c)(4) of the Uniform Firearms Ad) please Print Nsme and Provide Sianature
Hospital !Facility Providing Treatment /Address
N I
MH/MR f
303-304
TION BY (Please print name, address, area code, and telephone number of agency or county court.)
Offcer
Telephone
mitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Officer Edward E. Guido, Judge
Court Ca~e Number 21-2009-0722
Date of Court Order 9 / 3 ~ 2009
SIGNA URE OF NOTIFYING OFFICIAL eJ ~ g ~ ~~
....... .................................. ........................D.:t:....................~
NOTIFI ATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EX13TS
The physic n shall provide signed confirmation of the lade of severe mental disability following the initial examination under Section 302(b) of the
Mental Hea h Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Ad, Section 8111.1 (g)(3). Notice shall be transmitted by physidan
to the Penn ylvania State Police through the county Mental health and Mental Retardation Administrator or ental Flealth Review Officer.
Name - P ysician (Please print.)
Signature t Physician Date _ /
Original: Pennsylvania Stale Police
Copy: ounty Sheriffs Office (see web site: www.oa h rift' or for current sheriff information)