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------ <br />- -- ------------------------------ <br />-------------------------------------------------------- - <br />OMB APPROVAL DEPARTMEN F JUSTICE/DRUG ENFORCEMENT ADMINISTRAT'ON PACKAGE No. <br />No. 1117-0007 REGISTRANTS INVENTORY OF DRUGS SURRENDRED I <br />---------------------------------------------------------------------------------------------------------------- <br />The following schedule is an inventory of controlled substances which is hereby surrendered to you <br />for proper disposition. <br />FROM: (Include Name, Street, City, State and ZIP Code in space provided Below). <br />------------------------------------------------ <br />GUARANTEED RETURNS Signature of applicant or authorized agent <br />100 Colin Drive <br />Holbrook, NY 11741-4306 Registrant's DEA Number: RD0188311 <br />j Registrant's Telephone Number: (631) 689-0191 <br />„r DRUGS VIA U.S. POSTAL SERVICE: See instructions on reverse of form Page: ]. <br />NAME OF DRUG OR PREPARATION <br />Registrants will fill in <br />Columns 1,2,3 and 4 only <br />1 <br />1 DEMEROL INJ,USP 75MG/ML <br />2 MORPHINE SULFATE 15 MG <br />3 MORPHINE SULFATE 30 MG <br />4 MORPHINE SULFATE 100 MG <br />5 HYDROMORPHONE HCL 2 MG <br />6 MORPHINE SULFATE 20 MG/ML <br />7 DURAGESIC PATCH 50 MCG <br />8 DURAGESIC PATCH 100 MCG <br />DEA Form - 41 <br />(Jun. 1986) <br />CONTENTS (# (Controlled <br />lof grams,tablSubstance <br />I # of Ioz or other lContent <br />I Containers junits per I (Each <br />(container) I Unit) <br />2 I 3 I 4 <br />I 2.000 I 2.000 I 10.00 <br />1 I .550 I 100.00 <br />I 1 I .220 I 100.00 <br />1.000 I 1.000 I 100.00 <br />1 I .890 100.00 <br />3 2.958 I 1.00 <br />3 I 2.200 5.00 <br />I 1 I .800 I 5.00 <br />Previous edition dated 7/84 is usable <br />FOR DEA USE ONLY <br />QUANTITY <br />I DISPOSITION F--- - - <br />IGMS.I MGS. <br />5 1 6 1 7 <br />x See instructions on reverse side. <br />