HomeMy WebLinkAbout04-27-12SP 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 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 include adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, 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 class mail to the Pennsylvania State Police, Attention: PICS Unit, 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. § 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 ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT o4 ~ 1s X2012
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME WARFEL
FIRST GLADYS
MIDDLE L•
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 09 / 19 / 1924 SOCIAL SECURITY NUMBER 195-12-9619
SEX F RACE WHITE HEIGHT 5 ' 6 WEIGHT 120 LBS HAIR GREY
ADDRESS 46 ERFORD RD, CAMP HILL, PA 17011 (GOLDEN LIVING CENTER OF CAMP HILL)
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 Sistnature
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer CHRISTYLEE L. PECK
Court Case Number 21-2012-0186 Date of Court Order 04 / 16 / 1011
'?~ - d ~
SIGNATURE OF NOTIFYING OFFIC IAL. ~~~ ~ ~ ~ ~ ~ ~ ~ ~..~~~~-~ Date ~~` ~ /~~~/ `~. l~
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 Sectio~'302(b) of tt
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(3). Notice s~l~ transmitted by plj~sldiarl
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Officer u
Name -Physician (Please print.) _ ~ ~;~ r~
I,- ~_ ~ „~
Signature-Physician Date / / ~,-,~- ~» --;
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Original: Pennsylvania State Police ~ 1 ~ Y`~
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Copy: County Sheriff's Office (see web site: www.oasheriffs.or~ for current sheriff information) ~' ~,~-•
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