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HomeMy WebLinkAboutExample of Statement for Destruction of Dangerous Drugs 1977 STATEMENT FOR DESTRUCTION OF DANGEROUS DRUGS STATE OF TEXAS COUNTY OF Brazos We the undersigned Jerry M. Lester , an Investigator for the Texas State Board of Pharmacy, and Jerry Fickey Narcotics Officer , of Bryan (Position Held) (City) , County, Texas, pursuant to the provisions of Section 8 of Article 726d of the Penal Code and pursuant to the direction of the Texas State Board of Pharmacy, have destroyed those dangerous drugs set forth in the attached inventory, and hereby attest to the correctness of same. /� 1 Y�c / . f (:;) rd Invesltigator Offic 1 t://74:- STATE OF TEXAS COUNTY OF Brazos Before me the undersigned authority, on this day personally appeared Jerry M. Lester and Jerry Fickey who signed the above statement, and made oath that the same was true and correct. Sub- scribed to, before me, this 27th day of January 19 77 /C No ry Public in and for Brazos County, Texas DIVISION OF EMERGENCY MEDICAL SERVICES TEXAS DEPARTMENT OF HEALTH RESOURCES Austin, Texas 78756 PRESCRIPTION DRUG INVENTORY EMERGENCY HOSPITAL NO.: /0 _ /0 DATE: lr /mot /an -T 7 / �-� 77 ADDRESS :0��.4' ,0 _ , ,� ; to, Fv r / / , f t I certify that the prescription drugs listed below have been received this date. These drugs are to be destroyed as provided in Section 8 of the Texas Dangerous Drug Law. • Recipient : 411 9 f..t. AI; . ` 2. P L - � -- 4..... . • • • ent or Texas Stat -' :oar. di Pharmacy Witness: 4 t. / / Cus'todi an Amt. Fed. 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