HomeMy WebLinkAbout09-29-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) specifies 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 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. This would inGude adjudication of
incaparaty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notfication 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 Gass mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A Dopy of this form must also be torwarded to the sheriff of the county in which thls person
resides In accordance with 18 Pa.C.S. § 8109(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS"
Place an "X" on either Involuntary Commitmerk 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 o9 ~ za X2010
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME KING
FIRST GEORGE
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 01 / 14 / 1922 SOCIAL SECURITY NUMBER 184'12-2732
SEX M RACE CAU HEIGHT 6 ' 7 WEIGHT 185 HAIR GRAY EYES BLUE
ADDRESS CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT DRIVE CARLISLE PA
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment ^'
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act) Please Print Name and Pr `~
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rri ~._ >
Hospital l Facility Providing Treatment /Address n t'*1 L? ~. ~
r N r:' r'rj
^^~~~~~~a~~~~~~~~~~~u~~~~~~~~~~~~~~~~~~~a~~~~~~~~~~~~~~~~~~~~~~a~~~~~^`~AniA~~~~1iLi1~~~7Ti?Mit7~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agenc~~nty c~rt.) ~``' =;
MH/MR AdministratorlReview Officer Telephone ~ - ~ - rr'
T. <a
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & ortf¢i date z,
Judge/Review Officer J. WESLEY OLER, JR, JUDGE
Court Case Number 21-10-0842
SIGNATURE OF NOTIFYING OFFICIAL
.....................................
of Court Order 09 / 24 / 2010
Date `~ / ~ / Z o f ~
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 Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 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 / /
MIDDLE W
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.nasheriffs.org for current sheriff information)