HomeMy WebLinkAbout04-11-11 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Pa.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 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 firearns. This would indude adjudication of
incapacRy pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notficetion 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 dass mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the aherlH of the county in which this person
resides in accordance with 16 Pa.C.S. § 8109(i.1)(2). The envelope should be marked "CONFIDENTIAL-ATTENTION FlREARMS"
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incc~tpetent :~
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PRINT CLEARLY oR TYPE 302 303 3tM OTHER ~
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INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPET
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 04/08/2011 ~~O ~ ~^
COUNTY OF COMMITMENT Cumberland ~~ w `~
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Webber FIRST Marilyn MIDDLE J
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 10 / 15 / 1952 SOCIAL SECURITY NUMBER 181-42-8143
SEX F RACE Caucasian HEIGHT 5 ' 8 WEIGHT 121 HAIR Light Brown EYES Blue
ADDRESS 2108 Cedar Run Drive #103, Camp Hill PA 17011
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Un'rforn Firearms Act) Please Print Name end Provide Sianature
Hospital /Facility Providing Treatment /Address
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county wurt.)
MHMIR Administrator/Review Officer Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer Albert H. Masland, Judge
Court Case Number 21-2011-0362 Date of Court Order 04 / 08 / 2011
SIGNATURE OF NOTIFYING OFFICIA ~ Date y l ~~ l aDl/
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lads of severe mental disability following the inRial examination under Section 302(b) of the
Mental Health Procedures Ad and pursuant to the Pennsylvania Unicorn Firearms Ad, Section 6111.1 (g)(3). Notice shall be transmitted by physidan
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 / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.oasheriffs.ore for current sheriff information)