HomeMy WebLinkAbout10-29-09 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 16 Pa.C.S. 8105(c)(4) spedfies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involuntarily committed to a mental institution for inpatient care and treatment untler Section 302, 303, or 304 of the Mental Heakh
Procedures ad of July 9, 1976 (P.L. 617, No. 143) to possess, use, manutacture, control, sell or transfer firearms. This would include adjudication of
incepecity 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 edministiator within SEVEN
days of the adjudication, commitment or treatment by first Bass mail to the Pennsylvsnla State Police, Attention: PICS Unit, 1800 Elmsrton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the county In whleh this person
resides In accortlance with 18 Pa.C.3. § 6109(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS"
Place an "X" on either Involuntary Commitment and Indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 1o~zz~2009
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR
ADJUDICATED INCOMPE TENT
LAST NAME Colbert FIRST Rose
MIDDLE
JR., ETC. MAIDEN NAME ALIAS ~ Zi ~ r-i'i ,.>
DATE OF BIRTH 6 / 17 / 1927 SOCIAL SECURITY NUMBER m --1 c
=5 'n
SEX Female RACE er°nnm.n°° HEIGHT 5 , p „ 83
WEIGHT
HAIR Black ~
'~Y
ES
Br wn _
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ADDRESS 46 Erford Road, Camp Hill PA 17011 .
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302 Commitment Requires Physician's Certification ~ . ~;,
Physician Certifying NecessNy of Involuntary Commitment O ~'
(Requiretl in accordance vrith Section 6105(c)(4) of the Uniform Firearms Act) please Print Name and Provide Signature
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, case number, 8 order date
Judge/Review Officer Edward E. Guido, Judge
Court Case Number 21-2009-0863 Data of Court Order 10 / 22 / 2009
SIGNATURE OF NOTIFYING OFFICIAL Date ~~ /r~J Ir7
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physican shall provide signed confirmation of the lack of severe mental disability following the initial examination under Sedion 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Sedion 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 Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date _ / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.mash riff or for current sheriff information)