HomeMy WebLinkAbout06-02-11 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 Vansfer firearms. This would include adjudication of
inppadty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall be trensmiled
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 adjudigtion, commitment or treatment by first class mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A Dopy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with 18 Pa.C.3. § 6109(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS"
Placa 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 ADJUDICATED INCOMPETENT 05 ~ 27 ~ 2011
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME NICKEL
JR., ETC. MAIDEN NAME MASSEY
DATE OF BIRTH 12 / 15 / 1929
SEX F RACE CAU HEIGHT 5 ' 3_ __ " WEIGHT 135
ADDRESS 1000 CLAREMONT ROAD CARLISLE PA 17015
HAIR WH ~ EY~ BLUE
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)
Hospital /Facility Providing Treatment /Address
MIDDLE E
ALIAS
Please Print Name and
~ ..''
llV ~o p
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR AdministratorlReview Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer KEVIN A HESS, PRESIDENT JUDGE
Court Case Number 21-11-0452
of Court Order 05 / 27 / 2011
SIGNATURE OF NOTIFYING OFFICIAL `~`~ //"tf-~- Date ~ / ~ / Z o u
NOTIFICATION OF PHYSICIAN'S DETERMINATIO HAT NO SEVERE MENTAL DISABILITY EXISTS
The physican shall provide signed confirna0on of the lack of se re 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 Administretor or ental Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
SOCIAL SECURITY NUMBER 572-36-3771
FIRST IAVITA
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.pasheriffs.org for current sheriff information)