HomeMy WebLinkAbout10-12-09 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform 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 involuntady committed to a mental institution for inpatient care and treatment under Secfion 302, 303, or 304 of the Mental Health
Procedures ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would include adjudice8on of
incepadry pursuant to 20 Pa.C.S.A. 5501. Pursuant to fhe Pennsylvania Mental Health Procedures Ad, Section 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 vrithin SEVEN
days of the adjudication, commitment or treatment by first class mail to the Pennsylvania State Pollee, Attention: PICS Unh, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with 18 Pa.C.3. § 6109(1.1)(2). The envelope should be marked "CONFIDENTIAL-ATTENTION FlRE4RMS"
Place an "X" on either Involuntary Commitment and Intlicate 302, 303, 304, or Adjudleated Incompetent
PRINT CLEARLY oR TYPE 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 10/7/2009 ~O o ~F
~ m
CUMBERLAND
COUNTY OF COMMITMENT 7SC>
, - -~i it"~
c
,
r„ r
,. rm +
- v. ~., _., i_7
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICAI~I~OMP~TEN# '~?
LAST NAME AVENI
JR., ETC. MAIDEN NAME
DATE OF BIRTH 10 / 28 ,
SEX MALE RACE caucnsion
ALIAS
MIDj3L~ M 3 ~ ~ 'i~
n
~ r
v ~_
`
y ~
.,~ cry
-
1
1989 SOCIAL SECURITY NUMBER 194-70-2505
HEIGHT 4 ' 3 WEIGHT 116 HAIR BROWN EYES BLUE
ADDRESS 51 KENSINGTON DRIVE, CAMP HILL PA 17011
302 Commitment Requires Physician's Certification
Physician Certlfying Necessity of Involuntary Commibment
(Required in accordance with Sedion 6105(c)(4) of the Uniform Firearms Act)
Hospital /Facility Providing Treatment /Address
Please Print Name end Provide Slaneture
...a ......................................................................................r
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHRv1R Administrator/Review Officer Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, 8 order date
Judge/Review Officer
Court Case Number 21-09-0795 Date of Court Order 10 / 7 / 2009
SIGNATURE OF NOTIFYING OFFICIAL Date ~Q l ~~` l~dlr
...........................................................................................
x` NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lack of severe mental disability following the initial examination under Sedion 302(b) of fhe
Mental Health Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Ad, Sedion 6111.1 (g)(3). Notice shall be trensmitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
FIRST SEAN
Date
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www p heriff og for current sheriff information)