HomeMy WebLinkAbout01-06-12SP 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Aq, 18 Pa.C.S. 6105(c)(4) specifies that ft 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 aq of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufaqure, control, sell or transfer firearms. This would indude adjudication of
inppaaty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Aq, Segion 109, notification shatl be transmitted
to the Pennsylvania State Police by the judge, mental health review officer, or wunty 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 Dopy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with i8 Pa.C.8. § 6109(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS."
Place an "X" on either Involuntary Commitment and Indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE sot 303 304 OTHER
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INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPET, ^/ '=:
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12 30 2011 ~ '~ ~ '~
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT / / 7r` ~C'j z~, ;?` r'
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COUNTY OF COMMITMENT CUMBERLAND : '~L%i ~ ay '~' Tr','
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATEr~~ICOMPETENT ~. ~;
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LAST NAME STONER FIRST GLEN MIDDY _H ~ i'-- ~ '`
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JR., ETC. MAIDEN NAME ALIAS ~` -,r'
DATE OF BIRTH 09 / 06 / 1922 SOCIAL SECURITY NUMBER 196-14-4542
SEX MALE RACE CAUCASIAN HEIGHT 5 ' 3 WEIGHT 139 HAIR GREY EYES BLUE
ADDRESS 11 WHITMER ROAD, SHIPPENSBURG PA 17257
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance wfth Segion 6105{c){4) of the Uniform Firearms Aq) Please Print Neme and Provide 3tonature
Hospital !Facility Providing Treatment /Address
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NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR AdministratoNReview Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, 8~ order date
Judge/Review Officer Albert H. Masland, Judge /Cumberland County Orphans' Court, 1 Courthouse Square, Carlisle PA 17013 717-240-6345
Court Case Number 21-2011-1132
Date of Court Order 12 ~ 30 1 2011
SIGNATURE OF NOTIFYING OFFICIAL ~~~~ Date l ! Lt / l Z
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NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lack of severe mental disability following the initial examination under Segion 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Aq, 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 lieatth Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.Aasheriffs.ore for current sheriff information)