HomeMy WebLinkAbout11-24-09 (2) 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 involuntadly committed to a mental instttution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Healih
Procedures ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, 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, Section 109, notificedon 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, commitment or treatment by first dass mail to the Pennsylvania State Police, Attention: PICS Unlt, 1300 Elmerton
Avenue, Nanlsburg, 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.S. § 8108(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
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT Cumberland
11~z3~2009
'INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR
LAST NAME Hume
'v;% JR., ETC. MAIDEN NAME
DATE OF BIRTH 9 / 10 / 1944
SEX remeie RACE Caucasian
FIRST Susan
ALIAS
SOCIAL SECURITY NUMBER 202-36-6634
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HEIGHT WEIGHT HAIR EYES
ADDRESS 115 North 31st Street, Camp Hill PA 17011
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commibment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act)
Hospital /Facility Providing Treatment /Address
Please Print Name and Provide Sianature
..........................................................................................r
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, & order date
Judge/Review Officer Edward E. Guido, Judge
Court Case Number 21-2009-0908
Date of Court Order 11 / 23 / 2009
SIGNATURE OF NOTIFYING OFFICIAL _ ~"'1 Date ,/~ /~y / aoo 9
.......................................................................................... r
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability following the initial examinafion under Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 8111.1 (g)(3). Notice shall be transmitted by physidan
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Flealih Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: vw 's'ore for current sheriff information)