HomeMy WebLinkAbout04-26-12SP 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or
who has been involuntarily committed to a mental institution for inpatient pre 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 Include adjudiption of
inppacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notifiption 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 adjudiption, commitment or treatment by first class mail to the Pennsylvania State Police, Attention: PIGS Unit, 1800 Elmarton
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. § 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 302 303 3oa OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT Cumberland
ADJUDICATED INCOMPETENT Q~,
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR
LAST NAME Meredith
JR., ETC. MAIDEN NAME Grove
Please Print Name and Provide Signature
DATE OF BIRTH 05 / 23 / 1932 SOCIAL SECURITY NUMBER 200-24-2074
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SEX f RACE Caucasian HEIGHT 5 ' S WEIGHT 102 Ibs HAIR gray EYES green
ADDRESS At time of adjudication -Danville State Hospital, 200 State Hospital Drive, Danville Current-10058 S. Mountain Road, S. Mountain, PA
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
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
D
ALIAS
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer Edward E. Guido, Common Pleas Judge
Court Case Number 21-006-0294
SIGNATURE OF NOTIFYING OFFICIAL
.....................................
Date of Court Order O6 / 12 / 2006
Date ~ / ~V /
.........................................
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 Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(3). Notice shall be transmitted by physician
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 Constance
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.nasheriffs.org for current sheriff information)