HomeMy WebLinkAbout01-10-12SP 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 8105(c)(4) spedfies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involuntariy 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 transfer firearms. This would indude adjudication of
incepadty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall lxx 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, commitment or treatment by first Gass mail to the Pennsylvania State Police, Attention: PICS Unk, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with 18 Pa.C.S. § 8109(i.i)(2). The envelope should be marked "CONFIDENTIAL-ATTENTION FlREAi'~NS."
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Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Inca~b~ent s ~ x'
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PRINT CLEARLY oR TYPE 302 303 304 OTHER - ~+?, -
G~. in
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETF~~ ~e
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 01 ~ 09 ~ 2012 ~" ~:J ~`-
COUNTY OF COMMITMENT CUMBERLAND ~
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME PETERS
JR., ETC. MAIDEN NAME -
DATE OF BIRTH 12 / 16 / 1926
MILLER
SOCIAL SECURITY NUMBER
ALIAS _
174-20-4372
SEX FEMALE ~L.E CAUCASIAN HEIGHT 5 ' 0 WEIGHT 110 HAIR GRAY EYES BROWN
ADDRESS 210 BIG SPRING AVENUE, NEWVILLE PA 17241
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
Please Print Name and Provide Sianature
^.^.^ ......................^.....^^^^^..^^.....^^.^.^^.^^.^^^^^.^^...^^..^^.^^.a^^^a.^.^^.r
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county wurt.)
MHRvIR Administrator/Review Officer
MIDDLE JEAN
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer ALBERT H. MASLAND, JUDGE, CUMBERLAND COUNTY ORPHANS' COURT, 1 COURTHOUSE SQUARE, CARLISLE PA 17013
Court Case Number 21-2011-1207
Date of Court Order 01 / 09 / 2012
SIGNATURE OF NOTIFYING OFFICIAL' ~ Date ~ l ~ l `'~d l ~
NOTIFICATION OF PHY3ICIAN'3 DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lade of severe mental disability following the initial examination under Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms AG, 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 Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
FIRST VIVIAN
Date
Original: Pennsylvania State Police
Copy: County Sheriffs Office (see web site: www.masheriffs.ore for current sheriff information)