HomeMy WebLinkAbout06-21-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Un'rforn Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfies that tt shall be unlawful for any person adjudicated as an incompetent or
who has been involuntariy committed to a mental institution for inpatient care and treatment under Sedion 302, 303, or 304 of the Mental Health
Procedures ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufadure, control, sell or transfer firearms. This would indude adjudication of
inppaaty 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 administretor within SEVEN
days of the adjudication, commttmeni or treatment by first Bass mail to the Pennsylvania Stab Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff pf the county in which this person
resides in accordance with 18 Pa.C.3. § 6109(1.1x2). The envelope should be marked "CONFIDENTIAL -ATTENTION FlREAftMS"
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Place an "X" on either Involuntary Commitment and indicab 302, 303, 304, or Adjudicated Inc nt ~ , :.`
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PRINT CLEARLY oR TYPE 302 303 304 OTHER ~ ~ ~ ~ ' `-
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INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ~~-.; -~{
DATE OF QOMMITMENT OR ADJUDICATED INCOMPETENT os ~ 17 ~ 2010 = " _ ~ ~ : ~i
COUNTY OF COMMITMENT Cumberland =r> ..- `n
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Gober FIRST Lorraine MIDDLE B
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 02 / 27 / 1937 SOCIAL SECURITY NUMBER 179-30-7645
SEX F RACE White HEIGHT 5 ~ 3 ~~ WEIGHT 96 Ibs HAIR Salt 8 Pepper EYES Blue
ADDRESS Golden Living Center -Camp Hill, 46 Erford Road, Camp Hill PA 17011
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Sedion 6105(c)(4) of the Uniform Firearms Ad) Please Print Name and Provide Sianatura
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, & order date
Judge/ReviewQfficer Judge Edward E. Guido
Court Case Number 21-2010-0210
SIGNATURE OF NOTIFYING OFFICIAL
......................................
Date of Court Order 06 / 17 / 2010
............
Date ~ !~~ /1~
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 the
Mental Health Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Ad, Sedion 6111.1 (g)(3). Notice shall be transmitted by physician
to the Pennsylvania State Police through the county Mental health and Memel 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.pasheriffs.ore for current sheriff information)