HomeMy WebLinkAbout09-17-10 (2) P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Plt.C.S. 6105(c)(4) spedfies that R 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
Proceduroa ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufadure, control, sell or transfer firearms. This would indude adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental HeaRh Procedures Ad, Sedian 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 within SEVEN
days of the adjudication, commitment or troatment by first dass mail to the Pennsylvania State Police, Attention: PICS UMt, 1800 Elmerton
Avenue, Harrbburg, PA 17110. A copy of this form must also t» forwarded to the sheriff of the county in which this person
resides in accordance wkh 18 Pa.C.8. § 8109(i.i)(2). The envelope should be marked "CONFIDENTIAL-ATTENTION FIREAt~" _,-,
CC7r^~ c~ ~~ '-
Place an "X" on either Involuntary Commitment snd Indicate 302, 303, 304, or Adjudicated Inernt rn ~ t
tRt77 ^~~77 ~ ~ ~ ' .27
PRINT CLEARLY oR TYPE 302 303 304 OTHER ~~m - r"~~ rn
~
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETE ~,. Tl
~ '
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT o9~ 152010 p73 = -
°'~'
-c~--+
'N ;:,7 ~~
.J.
COUNTY OF COMMITMENT Cumberland ~
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Swanger Lois
FIRST MIDDLE J
JR., ETC. MAIDEN NAME Baldwin ALIAS
DATE OF BIRTH O6 / 02 / 1938 SOCIAL SECURITY NUMBER 188-32-5280
SEX Female RACE Caucasion HEIGHT 5 ' 0 WEIGHT 169.81bs. HAIR White EYES Hazel
ADDRESS Shippensburg HeaRh Care Center, 121 Walnut Bottom Road, Shippensburg PA 17257
302 Commitment Requires Physician's Certification
Physician Certifying Necessky of Involuntary Commitment
(Required in accordance with Sedion 8105(c)(4) of the Unfforn Firearms Ad) Please Print Name and provide Siansture
Hospital /Facility Providing Treatment /Address
^^^^^^^.^^.^^..^^.^.^^^^^.^..^^^^.^^..^^^^^^..^^^^^^^^^^^^.^..^^^^^^^^^^^^^..^^^.^.^^^^^^^r
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHMIR Administrator/Review Officer Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer Judge Albert H. Masland
Court Case Number 21-10-0843 Date of Court Order 09 / 15 / 2010
.,,. -
SIGNATURE OF NOTIFYING OFFICIAL Date ~/ `~/ .Z~~o
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lade of severe mental disability following the ini0al examination under Sedion 302(b) of the
Wtntal Health Procedures Ad and pursuant to the Pennsylvania Undortn Firearms Ad, Sedion 6111.1 (g)(3). Notice shall be transmitted by physidan
to the Pennsylvania State Police through the county Msntal health and AAental 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.orra for current sheriff information)