HomeMy WebLinkAbout06-07-11
SP 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH CO MITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) speafies that it shall be unlawful for any erson adjudicated .as an incompetent or
who has been involuntariy committed to a mental institution for inpatient care and treatment under Secti n 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 fi arms. This would Include adjudication of
incapaGty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, S coon 109, notificati n shall be transmitted
to the Pennsylvania State Police by the judge, mental health review officer, or county mental health and me tal retardation admi istrator within SEVEN
days of the adjudication, commitment or treatment by first Gass mail to the Pennsylvania State Police Attention: PICS nit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A Dopy of this form must also be forwarded to the sheriff of the county ih hich this person
resides in accordance with 18 Pa.C.S. § 6109(1.1)(2). The envelope should be marked "CONFIDE TIAL - ATTENTIO FIREARMS"
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Ad udicated Incompetent
PRINT CLEARLY oR TYPE 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED IN OMPETENT~ ^/ ~.
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 06 ~ 03 ~ 2011 _
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COUNTY OF COMMITMENT Cumberland ~
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED
OR AD t
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UDICATE~ PET~tT `,
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LAST NAME Thumma FIRST Delores
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MIDDLI
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JR., ETC. MAIDEN NAME Snyder ALIAS ~' lea
DATE OF BIRTH 02 / 17 / 1933 SOCIAL SECURITY NUMBER 184-26-3716
SEX Femme RACE Caucasian HEIGHT 5 ' 1 WEIGHT 260 ~
HAIR Brown
EYES Haze=
ADDRESS 1 Wertz Run Road, Carlisle PA 17013
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 nd Pr vie i n r
Hospital /Facility Providing Treatment /Address
NOTIFICATION BY (Please print name
address
area
d
,
,
co
e, and telephone number of gency or county] court.)
MH/MR Administrator/Review Officer
Tel
hone _
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, se number, & ~~rder date
Judge/Review Officer Edward E. Guido, Judge ~,
Court Case Number 21'2011-0465 ~ Date of Court O
______ der 06 ~ 03 '; ~ 2011
SIGNATURE OF NOTIFYING OFFICIAL ate ~o /d " /~ ~~
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DI BILITY EXIST
The physician shall provide signed confirmation of the IaGc of severe mental disability following the initial ex urination under 3e :tion 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(3). once shall be trans fitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Review C+f~i er.
Name -Physician (Please print.)
Signature -Physician
Date
Original: Pennsylvania State Police
Copy: County Sheriffls Office (see web site: www.pasheriffs ore for current sheriff information)
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