HomeMy WebLinkAbout10-19-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Penmsylvania Uniform Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfles 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 ad of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudication of
incepaaly pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Ad, Section 109, notficetron shall be transmitted
to the Pennsylvania State Police by the judge, mental health review officer, or wuMy mental health and mental retardation ~lministrator within SEVEN
days of the adjudication, commitment or treatment by first dass mail to the Pennsylvania State Pollca, Attention: PIGS Unit, 1800 Elmerton
resides in accordance with 18 Pa.C. g t1108ti.1x2). The envelope shou bermarked "CONFIDENTIAL ATTENTION FlIREA hl~s parson
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 INCOMPETENT ^~
DATE OF COMMITMENT OR ADJUDICATCD INCOMPETENT 10 / 18 / 2010
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
Barzda FIRST Mary MIDDLE A
LAST NAME
JR., ETC. MAIDEN NAME Gouse ALIAS
182-22-9716
DATE OF BIRTH 01 / 03 / 1928 SOCIAL SECURITY NUMBER
SEX Female RACE Caucasian ' 63 WEIGHT 84.6 lbs. HAIR Grey EYES Blue
HEIGHT
ADDRESS Church of God Home, 801 North Hanover Street, Carlisle PA 17013
302 Commitment Requires Physician's Certification
Physician Certlfying Necessity of Involuntary Commitrnent
(Required in accordance with Section 6105(c)(4) of the Un'rfomt Firearms Ad) PI@gs_e PrIM Name and Provlda Signature
Hospital /Facility Providing Treatment /Address
.^^...^^^^^.^^.^.^a.^^^^^.^^^^^^^rra^.^.^^e.^.a^^.^^^^a^ae^e^^^.^^^^.^a^^^^^^e^^^^a^e^^^..^~
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 21-2010-0875 Date of Court Order 10 / 18 / 2010
SIGNATURE OF NOTIFYING OFFICIAL ~ Date /O / ~ / ~~
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lads of severe mental disability folbwing the initial examination un Section 302(t>bof the
Mental Health Procedures Ad aril pursuant to the Pennsylvania Uniform Firearms Ad, Section 6111.1 (g)(3). Notice shall fitted by~rsidan
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Revi r r. Q r _
Name -Physician (Please print.) '~~ `~ -`r s + (~
-,~Zm ~ ~
.,, ~
Date / / a<~'^ ~ r ,J
Signature -Physician
J C? -ri 2 ~ _r-
Original: Pennsylvania State Police b --r ~':~ _ '~"
Copy: County Sheriff s Office (see web site: www.p~sheriffs.ore for current sheriff information) ~ t ~ <_~
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