HomeMy WebLinkAbout09-23-09SP 4131(5-2006) COMMONWEALTH OF PENNSYLVANIA
OF MENTAL HEALTH COMMITMENT as an incompetent or
NOTIFICATION erson adiudicated
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) specifies that it shall be unlawful for any p
to a mental institution for inpatient care and treatment under Se fi ea mOs ~ Th s wou d4include adejud cat onltof
sell or trans e
who has been involuntarily committed
Procedures act of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, Section 109, notification shall be transmitted
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to th Ith review) officernortcountylmental health and mental retardation ICSIUn tat1~' Elme~rton-,,
Attentionf~
to the Pennsylvania State Police by the judge, mental hea
which`{Als pelasor~~ ;~
days of the adjudication, commitment or treatment by fif ~~aTU t (also be forwardedito thessheriff~of the co N FIRE~M~" f~`~'- ~"~
PA 17110. A Dopy of this rked "CONFIDENTIAL - ATTE ',_., -~ .. >
u
Avenue, Harrisburg, 2 The envelope should be ma ~r ~ ~ ~ "p c`~~ -`".
resides in accordance with 18 Pa.C.S. § 6109(1.1)( ). _ .-,
nt fV ~~-' _ _'~'
« ~~ 'ther Involuntary Commitment and indicate 302, 303, 304, or Adjudicated I'~ Gn) ._:~ ~_. ,
Place an X on ei ---~ r.. '
INT CLEARLY oR TYPE 302 303 304 OTHER c~ ~ ~ = ' r-,
PR
^ ^ ADJUDICATED INCOMPE~E~NT ^ ~ ` ~' ~ ~ ,1
INVOLUNTARY COMMITMENT ^ ^
g ~17~9
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT CUMBERLAND
ON -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
INDIVIDUAL INFORMATI MIDDLE EVELYN
FIRST MIRIAM
LAST NAME ZUERNER
ZUERNER ALIAS NONE
JR., ETC. MAIDEN NAME
196-20-7669
DATE OF BIRTH 5 / 24 / 1924 SOCIAL SECURITY NUMBER BLUE
192 HAIR GRAY EYES
SEX F RACE CAUC HEIGHT 6 ' 2 WEIGHT
ADDRESS 210 BIG SPRING ROAD, NEWVILLE PA 17241
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Cthe Un form Firearms Act) Please Print Name and Provide Sis~nature
(Required in accordance with Section 6105(c)(4) o
Hospital /Facility Providing Treatment /Address
Y Please print name, address, area code, and telephone number of agency or county court.
NOTIFICATION B ( Telephone
MH/MR Administrator/Review Officer
uires the Judge/Review Officer name authorizing the commitment, case number, & order date
303-304 Commitment req
Judge/Review Officer J WESLEY OLER JR, JUDGE
Dat of Court Order 9 / ~ 7 / 2009
21-09-0701
Court Case Number
"~.. Date ~ Z-~ / ~'q
........ ....... ...............................
SIGNATURE OF NOTIFYING OFFICIAL
^ • • • • ^ • ^ • • • • • ^ • • • ^ • • ^ ^ ^ ^ • • • S DETERMIN TION THAT NO SEVERE MENTAL DISABILITY EXISTS
NOTIFICATION OF PHYSICIAN h sician
' e si ned confirmation of the lack of severe mental disability following 11 ;initta3) No !ce shall be transmitted by(p )y f t e
The physician shall proved g
Mental Health Procedures Act and pursuant to the Pen ntal health andrMental RetardaCon Adlministrator(or ental Health Review Officer.
to the Pennsylvania State Police through the county Me
Name -Physician (Please print.)
Date / /
Signature -Physician
Original: Pennsylvania State Police
Co County Sheriff s Office (see web site: www pasheriffs.org for current sheriff information)
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