HomeMy WebLinkAbout09-23-09 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 F.C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involuntariy 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 inGude adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall be Vansmittetl
to the Pennsylvania State Police by the jutlge, mental health review officer, or county mental health and mental retardation adminisbator wtthin SEVEN
days of the adjutlicetion, commitment or treatment by first class mail to the Pennsylvania State Polies, Attention: PICS Unit, 1600 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwsrded to the sheriN of the county in whleh this person
resides in accordance with 18 Pa.C.3. § 8109(1.1 )(2). The envelope should be marked "CONFIDENTIAL-ATTENTION flREARM3."
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adiudieated Incompetent
PRINT CLEARLY oR TYPE 3oz 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT _N
9 ~ 16 ~ 2009 ~ o°
COUNTY OF COMMITMENT Cumberland , q-D r*T ~_, ,_
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATEfI~tPETENT ~ ~ ~~
LAST NAME Beaudry FIRST Jacqueline vv = - ''
MIDDLFr'~~T' ~' '-'
JR., ETC. MAIDEN NAME Chouinard ALIAS v~ -~~ rt
DATE OF BIRTH 4 / 27 / 1922 SOCIAL SECURITY NUMBER 007-22-0544 0 -`
SEX Female RACE Caucesion HEIGHT ' S5 WEIGHT 951bs Gre
HAIR y EYES Hazel
ADDRESS Forest Park Health Center, 700 Walnut Bottom Road, Carlisle PA 17013
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Requiretl in accordance with Section 6105(c)(4) of the Uniform Firearms Act) Please Print Name and Provide~ionstLf6
Hospital /Facility Providing Treatment /Address
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, rase number, & order date
Judge/Review Officer
Court Case Number 21-2009-0644
ate of Court Order 9 / 16 / 2009
SIGNATURE OF NOTIFYING OFFICIA Date ZT
........................................ . ....... . ..................................
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVE E MENTAL DISABILITY EXISTS
The physician shall provitle signed confirmation of the lack of severe mental disability f lowing the initial examination under Section 302(b) of the
Mental Health Procedures AG and pursuant to the Pennsylvania Uniform Firearms AG, Se ion 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 Flealth Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date _ / /
Original: Pennsylvania State Police
Copy: County Sheriffs Office (see web site: www o ch riff or for current sheriff information)