NYS Department of Health V055 JAN 2 1 Quarterly Controlled Substance Inventory Form for ureau 0 area orcemen Humane Societies a! BI Hula-ME :I'tiol'cement Title 10 of New York State Rules and Regulations Part 80.13400 states: ?Quarterly reports. Within 10 days of the end ofeach quarter ot?ench year, the society or facility shall submit a report to the department signed by an of?cer or of?cial and the agent and (the information requested by LillS form). FacilityName {imam-4i Agent?s Name ?it? 3i *1 Address #00 Kid? PM ll ?3 it VDP State Zip Telephone Numberq 27 7" 4 2,3,5! i Bureau of Narcotic DEA Number Quarter {Mallet year Ll 0 0 Yr f-v Circle correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pentobarbital (Schedule Ketamine (Schedule 111) Previous Amount on Hand 0 Total Amount Received {3 Total Amount Utilized *Total Amount Lost 0 Ending Amount on Hand Number of Dogs Euthanized 0 Number of Cats Euthanizcd Other Species Euthanized (specify) Loss of controllcd?ys'tanccs must he reported to theBureau of Narcotic Enforcement. Briefly explain the loss. - .- Signed: xii/?? I Print Name: (i To be completed by registered agent: I certify that on i I I conducted a physical inventory on the controlled substances listed ebjiyc. Any ljfhas been noted. Under the penalties of perjur I af?rm that the statements made are Mme Signature of Agent Signal of 0 our of Society or Facility {Na/Ir Mag/X5? Date Date False made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 oftlre Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (7112) NEW STATE DEPARTMENT OF HEALTH Quarterl Controlled Substance Invento Form for 3! Bureau of Narcotic Enforcement Hu ane Societies Title to ofNew York State Rules and Regulations Part Elli. lit-Mk} stems; ?Quarterly reports. Withln It) days of the end of each quarter ofeach year, the society or facility shall submit a report In the department signed by an ot?licg?rr of?cial and the agent and (the information requested by this form). Facility Name 0 l. i?i? Agent?s Name ?9 i V'l Address [.1236 I i 7 0 Vi State Zip ?2 0 County Si LR S?it/ Telephone Number 37 7 '7 5719 Bureau of Narcotic Enforcement Certi?cate Number DEA Number (3) (4) ofyear?Z? 5 inch: correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pentobarbital (Schedule Ketamine (Schedule Previous Amount on Hand Total Amount Received Total Amount Utilized *Total Amount Lost Ending Amount on Hand Number of Dogs Euthanized 6? Number of Cats Euthanized Other Species Euthanized (specify) Cl Loss of must be?ybported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: a Print Name: . . g] To be completed by registered agent: I certify that on Honducted a physical inventory on the controlled substances listed at: c. Any loss ?chen noted. Under the penalties of perjury, I af?rm that the statements made are true. "f - . - ,i :47. in r" fr? - Uri/'4 {.26 ., 3/92 Signalilre of A of?! . Signature of Of?cer of Society or Facility 2/ - - fl 31/ Date Date False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210. 45 of?re Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866)811-7957 DOH-4331 (7112) NEW YORK STATE DEPARTMENT OF HEALTH Quarterly Controlled Substance Inventory Form for Bureau of Narcotic Enforcement Humane societies Title [0 ot'New York State Rules and Regulalions Part 80. l34(k) states: ?Quarterly reports. Within 10 days ol' the end of each quarter of each year, the society or facility shall submit a report to the department signed an of?cer or official and the agent and include. . (the information requested by this form). Facility Name I Agent?sName Address Ian}; 10 . State Zip lb'Tlr) CouniLlAlEthQ?er Telephone Number Ely 0 Bureau of Narcotic Enforcement Certi?cate Number DEA Number loioo Circle correct qumlcr Mixture of Sod. Pentobarbital (Schedule Ketamine Previous Amount on Hand 5q 0 Total Amount Received C) Total Amount Utilized 5 Lo *Total Amount Lost 3 iAmnu'nt oil-Hand a Number of Dogs Euthanized Number of Cats Euthanized Other Species Euthanized (specify) C) Loss of controlled tibslanccs must be rcpo ted to the Bureau of Narcotic Enforcement. Brie?y explain the loss. 37/. hi" .71? Print Name: To be completed by registered agent: I certify that on if?/ I conducted a physical inventory on the controlled substances listed above. Any loss has?otetl. Under the penalties of perjury, I af?rm that the statements made are true. 19"? 5 ?r7 l1 Signature of Agent Signature of fficc 0 Society or Facilit *1 lZ-ll?a/ f/g/ie? Date Date Signed: False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 of?ce Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866) 811?7957 OOH-4331 (7112) NYS Department of Health NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement 1 3 zmuarterly controued SUbStance Bureau of pierce-tit. "t Title [0 ofNew York State Rules and Regulations Part 80. l34(k) states: ?Quarterly reports. Within 10 days of em] of each quarter ol'enuli year, the society or facility shall submit a report to the department signed by an of?cer or of?cial and the agent and include. . (the informalion requested by this form}. Facility Name 1 Aim Wt f-l?l 3,1 Agent?s Name 65.. 61; pi. Address I Nllb?i?g State Zip 0 County 9/ Telephone Number kis? 3 7 Bureau oanrootic Enforcement Certi?cate Nun: er 1 A DEA Number jar/i4 I 14%: Staff Circle correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pentelrarbital (Schedule [(etamine (Schedule Previous Amount on Hand 3 Total Amount Received a Total Amount Utilized C) *Total Amount Lost Ending Amount on Hand k1? Number of Dogs Euthanized 0 Number of Cats Euthanized Other Species Euthanized (specify) 0 Loss of controlled ylb??ch so must be reported he Bureau of Narcotic Enforcement. Brie?y explain the loss. 1" Signed: $1,561 Print Name: fa? To be completed by registered agent: I certify that I conducted a physical inventory on the controlled substances listed Any loss has en nbted. Under the penalties of peWaf?r that the statements made are true. WV WM gignature of A cut 5/ Signature of Officer of Society or Facility 0/ 5 [em 5* Date I Date I False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 of the Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866) 811-7957 oon4331 (7/12)