HomeMy WebLinkAbout09-23-09 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Unrfortn Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involunladly committed to a mental institution for inpafienl care and treatment under Sedion 302, 303, or 304 of the Mental Health
Procedures ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufadure, control, sell or transfer firearms. This would indude adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Ad, Sedion 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, cemmttment or treatment by first Gass mail to the Pennsylvania State Pollee, Attention: PICS Unh, 1800 ElmeRon
Avenue, Harrisburg, PA 17110. A copy of this form must slso be forwarded to the sheriff of the county In whleh this person
resides In aeeordance with 18 Pa.C.3. § 8109(1.1 )(2). The envelope should be marked "CONFIDENTIAL-AT~E~IiION FlREJ~IS'
C~'pp ~~ .°o n
Plaee an "X" on either Involuntary Commitment end indleate 302, 703, 304, or AdJudieated Ir~tsnt H n ~: 7
1J r ~ c' ~c
PRINT CLEARLY oR TYPE 302 303 304 OTHER
I'a°cn~ w ~~~,~
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPEr~ _ `-_ `~?
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 9 / 1x/2009 ~~ G7 ' =i
v
COUNTY OF COMMITMENT Cumberland O
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Beaudry FIRST Robert MIDDLE M
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 5 / 12 / 1923 SOCIAL SECURITY NUMBER 007-14-9889
SEX Male RACE Caucesion HEIGHT ' 65 WEIGHT 118 Ibs HAIR White EYES Brown
ADDRESS Forest Park Health Canter, 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 Ad) Please Print Name and Provide Signature
Hospital /Facility Providing Treatment /Address
..........................................................................................r
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHM1R Administrator/Review Officer Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer _....~
Court Case Number 21-2009-0733 ate of Court Order 9 / 16 / 2009
SIGNATURE OF NOTIFYING OFFICIA Date Q / L3/ 0 q
.......................................... .. ... ......................................r
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEV RE MENTAL DISABILITY EXISTS
The physidan shell provide signed confirmation of the lack of severe mental disability following the initial examination under Sedion 302(b) of the
AAental Health Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Ad, Sedion 6111.1 (g)(3). Notice shall be lrensmided by physidan
to the Pennsylvania State Police through the county Mental health antl Mental Retardation Administrator or ental HeaIM Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania Slate Police
Copy: County Sheriff s Office (see web site: www.masheriffs.ore for current sheriff information)