HomeMy WebLinkAbout03-30-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Unrfomt Firearms Act, 18 Pa.C.S. 6105(c)(4) spedfies that fi shall be unlawful for any person adjudicated as an incompetent or
who has been involuntarily committed to a mental instftution for inpatlent care and treatment under Section 302, 303, or 304 of the Mental Health
Procedures act of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms, Thia would include adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall be transmitted
to the Pennsylvania State Pogce by ~ j~9e mental health review officer, or county mental health and mental retardation administrator within SEVEN
days of the adjudication, commitment or treatment by first Bass mail to the Pennsylvania State police, Attentlon: PICS Unit, 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.s. § 6108(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FlREARMS."
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 INCOMPET ^/ 4
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 03~29~2010 ~ ~ '±~ ~'
COUNTY OF COMMITMENT Cumberland
c~,~~ ~ =_
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATE ~ O~MpET~JT c ",-,I
LAST NAME Dell Arlene ,_
FIRST MIDDLB~E=i ~ `T'
JR., ETC. ~_MAIDEN NAME Keefauver ALIAS v ` ,~ ~'
DATE OF BIRTH 10 / 11 / 1925 SOCIAL SECURITY NUMBER
207-22-1938
SEX F RACE W HEIGHT 5 5
' WEIGHT 109•--~_ HAIR Light Gray Blue
ADDRESS Manor Care Nursing Home, 940 Walnut Bottom Road, Carlisle PA 17015 EYES
302 Commttmt3nt Requires Physician's Certification
Physician CertHying Necessity of Involuntary Commibment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act) please Pr_ i~m~ a~ provide 3ianatu~~
Hospital /Facility Providing Treatment /Address
..^^^^..^~~~^..^^s•^.^~~^^..^^u...~s•^^.^^u.^^~a^^.^s~^^^ssu^..^~~~^.^~ u.^^~~^^^^s~^^.~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHMIR Administrator/Review Officer
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment) cahsennumber, & order date
Judge/Review Officer
Court Case Number 21-2010-0210
Date of Court Order 03 / 29 / 2010
SIGNATURE OF NOTIFYING OFFICIAL /I
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 examination under Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania UnHorn Firearms Act, Section 6111.1
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administretor(or entaNHece sh~alV'be t~s Bitted by physican
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: ~v,rach_ e_ n__ fig org for current sheriff information)