HomeMy WebLinkAbout11-17-11SP 4031 (698) COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Uniform Firearms Act, 18 PA. C.S. 8105 (c)(4) speGllea that it shall be unlawful for any person adjudicated as an incompetent or who has been Invduntarily canmitted t0
a mental inatitutbn for Inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures Act o} Jury 9, 1978 (P.L.817, No. 143) to possess, use,
manufacture, contra, sell or transfer firearms. This would include adjudice0on of incapacity pursuant to 20 Pa.C.S.A. §5501. Pursuant to the Pennsylvania Mental Health
Procedures Act, Sectlon 109, notiflcatbn 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 ad)udication, commitment or treatment by first Casa mail ro the Pennsylvania State Police, Attention Firearm Unit, 1800
Elrtromon Avenue, HaMsburg, PA 17110. NOTE: The envelope shall be marked'CONFIDENTNL.'
Place an "X" on either involuntary Commitment or Adjudicated Incompetent
INVOLUNTARY COMMITMENT
ADJUDICATED INCOMPETENT X
Date of Involuntary Commitment or Adjudicated Incompetent
INDIVIDUAL INFORMATION (INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT)
LAST NAME: MAYO FIRST: EDITH MIDDLE: MAY
JR., ETC. MAIDEN NAME: CURRY ALIAS
DATE OF BIRTH: 05/02/33 SOCIAL SECURITY NUMBER: 113-26-1058
SEX: F RACE: CAUCASIAN HEIGHT: 5'2" WEIGHT: 180 HAIR: GRAY EYES: BROWN
ADDRESS: WEST SHORE HEALTH AND REHABILITATION CENTER, 770 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
NOTIFICATION BY (Please print name, address, area code, and phone number of agency or county court.)
County Submitting Notification CUMBERLAND
County Mental Health and Mental Retardation Administrator ~,~
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County Mental Health Review Officer u ,. ; r
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Physician Certifying Necessity of Involuntary Commitment o ` " `-_'
(Required in accordance with Section 6f 05(c)(4) of the Uniform Firearms Act)
HospitaVFacility Providing Treatment/Address
Judge
SIGNATURE OF NOTIFYING OFFICIAL
Court Case Number
DATE
Date of Court Order
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NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The phyaidan shall provide signed confirmation of the determination of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental
HeelBt Procedures Ad and pureuaM to the Uniform Firearms Ad, Section 8111.1 (g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through
the county mental heaRh and merdal retardation edminlstretor or mental review officer.
Name of Physician (Please print.)
Signature of Physician Date