HomeMy WebLinkAbout09-13-11 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Pa.C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involuMariy commkted to a mental instituters for inpatient care and treatment under Sedlon 302, 303, or 304 of the Mental Health
Procedures act of July 9, 1975 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Ad, Section 108, notification 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, commNment or treatment by first dass mail to the Pennsylvania Stsb Polies, Attention: PICS Unk, 1800 Elrrrerton
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. § 8109(1.1)(2). The envelope should be marked "CONFIDENTIAL - AT1EN71pN FIREARMS"
Place an "X" on either Involuntary Commitment snd indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY aR TYPE 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETI~~C/,] ~.`
08 25 2011 ~~~~ t rj ~? t ~`~
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT / / ~ -~~ ~'
r- ~ ``" r
COUNTY OF COMMITMENT CUMBERLAND x~ -
~ ~ f> `
INDIVIDUAL INFORMATION
LAST NAME KING
i~~ `? -T
-INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATE[?OMPETLNT - ' i
FIRST WALTER MIDDLL° E r~ r`= m
f.r- ,
JR., ETC. MAIDEN NAME ALIAS ~
DATE OF BIRTH 08 / 04 / 1944 SOCIAL SECURITY NUMBER 208-38-7204
SEX MALE RACE CAUCASUIN HEIGHT 5 ' 2 WEIGHT 179 HAIR G~`Y EYES BLUE
ADDRESS 2010 BIG SPRING AVENUE, NEVVVILLE PA 17241
302 Commitment Requirtas Physician's Certification
Physician Certifying Necessity of Involuntary Commibnent
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Ad) Please Print Name and Provide Sianature
Hospital /Facility Providing Treatment /Address
^^^.^.^eee^...^e^^e.^^.^^^^..^.^^^^^.^^^^^^e^ee^•.ee^^^^^e^^e^^^^.^^^^^.^^^^^^ee^^^e^^^e^^r
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHMIR Administrator/Review Officer CUMBERLAND COUNTY ORPHANS' COURT Telephone 717-240-6345
303-304 Commitment requires the Judge/Review Officer name authorizing the commkment, case number, 8 order date
Judge/Review Officer J. WEuLEY OLER; JR., JUDGE
Court Case Number 21-2011-0717 ~ Date Court Order 08 / 25 / 2011
SIGNATURE OF NOTIFYING OFFICIAL Date `l / ~ 3/ 11
NOTIFICATION OF PHYSICIAN'S DETERMI ION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lade o severe mental disability following the initial examination under Section 302(b) of the
AAantal Health Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Act, Sedion 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 Flealtlt Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www Dasheriffs.o~ for current sheriff information)