HomeMy WebLinkAbout01-20-12SP 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfies that tt 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
Prooadures ad of July 9, 1878 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudication of
incapadty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Ad, Section 109, 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, commitment or treatment by first Bass mail to the Pennsylvania State Police, Attention: PICS Unif, 1600 Elmertom
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. § 6108(i.1H2). The envelope should be marked "CONFIDENTIAL-ATTENTION FIREA~AS"
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated I~ompetent ~,v .
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PRINT CLEARLY txt TYPE 3oz 303 304 OTHER ~~ <~ -
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INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPEI~''.^O ~'
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 01 ~ 19 ~ 2012 ~ ~. -.
COUNTY OF COMMITMENT CUMBERLAND ~ -1 r,, ;; `'~ r'--,
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME COCKLIN
JR., ETC. MAIDEN NAME
DATE OF BIRTH 06 / 02 / 1918
FIRST ADA
ALIAS
MIDDLE GRACE
SOCIAL SECURITY NUMBER 209-12-5749
SEX FEMALE RACE CAUCASIAN HEIGHT 5 ' 1 WEIGHT 156
ADDRESS 1000 CLAREMONT ROAD, CARLISLE PA 17015
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Ad)
Hospital /Facility Providing Treatment /Address
Please Print Name and Provide Signature
^^....^^^^^.^.^..^^^^^^^^^^^s^.^^^s^^^^^^^^.^..^^^^.^^^..^..^..^^^^.^^^......^.^^^^^^^^^^^~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or aunty court.)
MH/MR Administrator/Review Officer Telephone 717-240-6345
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer JUDGE ALBERT H. MASLAND, CUMBERLAND COUNTY ORPHANS' COURT, ONE COURTHOUSE SQUARE, CARLISLE PA 17013
Court Cese Number 21-2011-1291 Date of Court Order 01 / 19 ~ 20127
SIGNATURE OF NOTIFYING OFFICIAL ~ Date l / o~ /~ z
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability following the initial examination under Section 302(b) of the
Mental Health Procedures Ad and pursuant to the Pennsylvania Uniform Firearms Ad, Section 6111.1 (g)(3). Notice shall be transmitted by physican
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
HAIR WHITE EYES BLUE
Date / /
Original: Pennsylvania State Police
Copy: County Sheriffls Office (see web site: www.pasheriffs.ore for current sheriff information)