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From the 11/19/2021 release of VAERS data:

Found 4,746 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

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VAERS ID: 1421090 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-19
Onset:2021-06-09
   Days after vaccination:82
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Angiopathy, Chronic obstructive pulmonary disease, Coronary artery disease
SMQs:, Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Advanced coronary artery disease, Arteriovascular risk factors, Chronic obstructive lung disease.COVID-19 2/10/2021, Recurrent GI bleed with iron deficiency


VAERS ID: 1421273 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-06-18
Onset:2021-06-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009C21A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 0
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 325 mg tablet 650mg TABLET NG-Tube PRN Every 4 Hours CO acetaminophen 325 mg tablet 650mg TABLET NG-Tube PRN Every 4 Hours DC albuterol sulfate HFA 90 mcg/actuation aerosol inhaler 2 PUFFS HFA AEROSOL WITH ADAPTER (GRAM) Inhal
Current Illness: REPIRATORY FAILURE WITH HYPOXIA C4 FRACTURE STAGE 4 PRESSURE INJURY OF SACRUM DYSPHAGIA PNEUMONIA SEVERE CALORIE MALNUTRIRION
Preexisting Conditions: DM TYPE 2 HYPERTENTION HYPERCHOLESTEROL ASTHMA
Allergies: PCN
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH WITHIN 24 HOURS


VAERS ID: 1421533 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-06-21
Onset:2021-06-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Confusional state, Death, Dyspnoea, Feeling abnormal, Pyrexia, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine, lisinopril, metoprolol, eliquis, sertraline, pregabalin, hydrocodone, trazodone, clonazepam, on an insulin pump
Current Illness: Left fore-foot amputation with open wound, improving and undergoing appropriate care
Preexisting Conditions: diabetes mellitus - most recent check A1c 7.3 (well controlled) with complications (nephropathy, neuropathy, gastroparesis); history of SVT and HTN well controlled; history of venous thromboembolism on eliquis life-long; carotid artery stenosis , severe; obstructive sleep apnea
Allergies: NSAID (rash and throat swelling), latex, penicillin
Diagnostic Lab Data: Unclear, patient was hospitalized when she died. I am reporting as her PCP and the location that gave the vaccine. Per her husband, he has not been given a cause of death, and was not offered an autopsy.
CDC Split Type:

Write-up: Per report from patient''s husband, the patient developed a fever to 103 on the evening of 6/21/21. She awoke in the morning and was "not herself". He describes her as having difficulty breathing and not being lucid. He took her to the hospital where she was hospitalized and then he got a call from the hospital in the evening reporting that she had walked to the restroom and then collapsed. Per his report, she had CPR performed for 30 minutes prior to being declared deceased. His phone number is the one included in this report.


VAERS ID: 1421767 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aciphex Vit E 400mg Metoprolol 100mg Aspirin 81mg B Complex Vit 2 50,000mg Trulicity 1.5 shot Pralvent 1.5 shot Fish Oil COQ10 SG 100 Clindamycin 150mg Colace Flomax .4 1000mg Metformin
Current Illness: Had Stint and Quadruple by pass, High Cholesterol, High Triglycerides, Coronary Heart Disease, Sleep Apnea, Acid Reflex, Diabetes Had Surgery 1 week prior for prostrate cancer.
Preexisting Conditions:
Allergies: Penicillin Suffa Terramycin All Statin - drugs
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died


VAERS ID: 1421819 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-01
Onset:2021-04-02
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032B21A / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Feeling abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Pt took a diuretic and another unknown medication for hypertension
Current Illness: None
Preexisting Conditions: Hypertesnsion
Allergies:
Diagnostic Lab Data: unknown- Pt was transported to Medical Center ER 4/19/2021
CDC Split Type:

Write-up: Pt was vaccinated on 3/31/2021. His long time partner reported that he started feeling a little off 2 days post vaccination, he thought he had indigestion. Over the next few weeks he began feeling worse especially with exertion. While at work on 4/19/2021 he told his friend that he hadn''t been feeling well for 3 weeks. Shortly after reporting this he went into Cardiac arrest. He was transported to Medical Center, where he was pronounced dead. His partner reports he was healthy with the exception of hypertension. She reports he was thin, never smoked, didn''t drink alcohol and rarely used marijuana. She reports only a visual autopsy was performed and pt was cremated.


VAERS ID: 1422827 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1423055 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-05-13
Onset:2021-05-27
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea, Myocardial infarction, Palpitations, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: suffered a massive heart attack; Feeling of faintness; Palpitations; Shortness of Breath; This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDIAL INFARCTION (suffered a massive heart attack), SYNCOPE (Feeling of faintness), PALPITATIONS (Palpitations) and DYSPNOEA (Shortness of Breath) in a 59-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On 13-May-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 27-May-2021, the patient experienced SYNCOPE (Feeling of faintness) (seriousness criterion medically significant), PALPITATIONS (Palpitations) (seriousness criterion medically significant) and DYSPNOEA (Shortness of Breath) (seriousness criterion medically significant). On 09-Jun-2021, the patient experienced MYOCARDIAL INFARCTION (suffered a massive heart attack) (seriousness criteria death and medically significant). The patient died on 09-Jun-2021. The reported cause of death was suffered a massive heart attack. It is unknown if an autopsy was performed. At the time of death, SYNCOPE (Feeling of faintness), PALPITATIONS (Palpitations) and DYSPNOEA (Shortness of Breath) outcome was unknown. No concomitant information was reported. No treatment information was reported. Action taken with mRNA-1273 was not applicable. A Patient called to report that two weeks after the first dose of the Moderna Covid-19 vaccine on 27-May-2021, his boyfriend began to experience palpitations, shortness of breath and feeling of faintness. The caller stated that her boyfriend did not want to go to the emergency room and only set an appointment with his Health Care Provider, but on the 09-Jun-2021, the day that he was going to the appointment, he suffered a massive heart attack and passed away. This is a case of sudden death in a 59-year-old male subject, who died 23 days after receiving first dose of vaccine. Very limited information has been provided at this time. Patient medical history was not provided.; Sender''s Comments: This is a case of sudden death in a 59-year-old male subject, who died 23 days after receiving first dose of vaccine. Very limited information has been provided at this time. Patient medical history was not provided.; Reported Cause(s) of Death: suffered a massive heart attack


VAERS ID: 1423057 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Polio
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Problems breathing; This spontaneous case was reported by an other health care professional and describes the occurrence of DYSPNOEA (Problems breathing) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Polio. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On an unknown date, the patient experienced DYSPNOEA (Problems breathing) (seriousness criterion death). The reported cause of death was problems breathing. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Concomitant medications was not provided. Treatment medications was not provided. Action taken with mRNA-1273 in response to events was not applicable. As a young child, patient was in an iron lung. This is a case of fatal Dyspnoea in a male subject with a hx of polio, who died after receiving the second dose of vaccine. Very limited information has been provided at this time.; Sender''s Comments: This is a case of fatal Dyspnoea in a male subject with a hx of polio, who died after receiving the second dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Problems breathing


VAERS ID: 1423241 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Other       Purchased by: ?
Symptoms: Death, Dyspnoea, Endotracheal intubation, Mechanical ventilation, Mobility decreased, Peripheral swelling, Posture abnormal
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID positive in December 2020
Preexisting Conditions: COPD, CHF, Kidney Disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within 24 hours, my mom''s arms swelled up from shoulder to fingertips and she had never had swelling in her arms prior. She also was hanging her head as if she had fallen asleep, but actually was unable to lift her head. 4 days following the vaccine she started having breathing issues and was intubated, we had the ventilator removed (she was actually a DNR and was not supposed to be intubated). On January 19, 2021 she died. She went into this facility for rehab regarding an infection she had in her leg.


VAERS ID: 1423287 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-24
Onset:2021-02-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Will provide -
Current Illness: none
Preexisting Conditions: Aortic stenosis COPD Fatty liver
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his second Moderna vaccine on 02-24-21. He began to experience chest pains on mild exertion on 02-26-21. He then suffered a heart attack on 03-08-21 and passed away.


VAERS ID: 1423308 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-04-07
Onset:2021-06-07
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Endotracheal intubation, Lymphadenopathy, Lymphoproliferative disorder, Sepsis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Haematological tumours of unspecified malignancy (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Xanax 1mg, chlorthalidone 25mg, celexa 40mg
Current Illness:
Preexisting Conditions: Bipolar 1, HTN, Obesity
Allergies: clavulanic acid, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient complained of intermittent fevers since the first administration of the Moderna vaccine on 4/7/21. fevers continued intermittently until second moderna dose on 5/5/21. Patient developed lymphadenopathy and eventually was hospitalized on 6/6/21 for sepsis symptoms. Patient was intubated and found to have an acute lymphoproliferative disorder that caused cardiac arrest and the patient expired on 6/8/21. She has no lab abnormalities suggesting a lymphoproliferative disorder prior to these events.


VAERS ID: 1423365 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-23
Onset:2021-03-30
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Product administration error, Respiratory disorder, SARS-CoV-2 test negative, Urinary tract infection
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Medication errors (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown.
Current Illness: Unknown.
Preexisting Conditions: Alzheimer, respiratory problems.
Allergies: Unknown.
Diagnostic Lab Data: Covid-19 antigen test, negative result.
CDC Split Type:

Write-up: Died in the hospital. Was admitted due to respiratory problems, had urinary tract infection, had complications with medications administered at the hospital ( did not specified which ones).


VAERS ID: 1423631 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-05-19
Onset:2021-06-12
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004C21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol sulfate simvastatin prazosin amLODIPine
Current Illness:
Preexisting Conditions: cardiac pacemaker in situ essential hypertension
Allergies: Sulfa (Sulfonamide Antibiotics)
Diagnostic Lab Data:
CDC Split Type:

Write-up: FAMILY PRACTICE was notified by a County coroner that the patient died on 12 June 2021. It is unknown to us if this is related to the Moderna vaccine received 19 May 2021. Dr. had seen this patient one time as a new patient of FAMILY PRACTICE to establish a primary care provider 25 May 2021 FAMILY PRACTICE provided the 1st dose Moderna vaccination 19 May 2021


VAERS ID: 1423777 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-14
Onset:2021-03-08
   Days after vaccination:53
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute myocardial infarction, Cardiac failure, Condition aggravated, Death, Dementia, Dysphagia, Hypophagia, Laboratory test, Pneumonia, Respiratory failure
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (narrow), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Pneumonia
Preexisting Conditions: Nstemi, dysphagia secondary to severe dementia., Other: Severe debility, dementia, dysphagia, poor po intake
Allergies:
Diagnostic Lab Data: Antigen test Causes of death listed on patient''s death certificate: 1) Respiratory failure secondary to pneumonia and heart failure, 2) pneumonia, 3) Nstemi, 4) dysphagia secondary to severe dementia., Other: Severe debility, dementia, dysphagia, poor po intake
CDC Split Type:

Write-up: Death 3/8/2021


VAERS ID: 1423868 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-03
Onset:2021-03-18
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Death, Polymerase chain reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Severe symptomatic aortic stenosis, coronary artery disease status post percutaneous coronary intervention
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 3/18/2021 Causes of death listed on patient''s death certificate: 1) Acute cessation of cardiac function Other: Severe symptomatic aortic stenosis, coronary artery disease status post percutaneous coronary intervention


VAERS ID: 1424014 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-04
Onset:2021-03-22
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Obesity, Respiratory failure, Rheumatoid arthritis, Type 1 diabetes mellitus
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Arthritis (narrow), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Rheumatoid Arthritis, Insulin Dependent Diabetes, Chronic Hypoxic Respiratory Failure, Morbid Obesity
Allergies:
Diagnostic Lab Data: 1) Sequelae of SARS-Coronavirus 2019 Other: Rheumatoid Arthritis, Insulin Dependent Diabetes, Chronic Hypoxic Respiratory Failure, Morbid Obesity
CDC Split Type:

Write-up: Death 4/18/2021 Causes of death listed on patient''s death certificate: 1) Sequelae of SARS-Coronavirus 2019 Other: Rheumatoid Arthritis, Insulin Dependent Diabetes, Chronic Hypoxic Respiratory Failure, Morbid Obesity


VAERS ID: 1424069 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-17
Onset:2021-03-22
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cardiac arrest, Death, Nucleic acid test, Polymerase chain reaction
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19 pneumonia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 3/31/2021 Causes of death listed on death certificate: 1) Cardiac arrest 2) covid 19 pneumonia


VAERS ID: 1424081 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-23
Onset:2021-03-26
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory failure, Atrial fibrillation, COVID-19, Chronic kidney disease, Condition aggravated, Death, Diabetes mellitus, Nucleic acid test, Polymerase chain reaction
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Chronic kidney disease (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19
Preexisting Conditions: Chronic kidney disease, diabetes mellitus, atrial fibrillation
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 4/7/2021 Causes of death listed on death certificate: 1) Acute respiratory failure 2) Chronic kidney disease 3) Diabetes mellitus 4) Atrial fibrillation Other: COVID 19


VAERS ID: 1424095 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-05
Onset:2021-03-22
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Myocardial infarction, Nucleic acid test, Polymerase chain reaction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 3/23/2021 Cause of death listed on death certificate: Myocardial Infarction


VAERS ID: 1424120 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-04-11
Onset:2021-04-23
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Diabetes mellitus, Hypertension, Nucleic acid test, Polymerase chain reaction, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypertension (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19
Preexisting Conditions: Diabetes Mellitus Hypertension
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 04/23/2021 Causes of death listed on death certificate: 1. hypoxic respiratory failure 2. covid 19 3. diabetes mellitus 4. hypertension


VAERS ID: 1424124 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-06-19
Onset:2021-06-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The pharmacist was contacted by patients daughter on 6/23/2021. She said that patient was found deceased on the morning of 6/20/2021. They believe he passed away sometime on 6/19/2021.


VAERS ID: 1425847 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-31
Onset:2021-04-14
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021B21A / 2 - / -

Administered by: Other       Purchased by: ?
Symptoms: Coronary artery disease, Death, Diabetic nephropathy, End stage renal disease, Hypertension, Nucleic acid test, SARS-CoV-2 test, Type 2 diabetes mellitus
SMQs:, Rhabdomyolysis/myopathy (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Other ischaemic heart disease (narrow), Chronic kidney disease (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: 1) End Stage Renal Disease 2) Diabetes Type 2 with nephropathy 3) Hypertension 4) Coronary Artery Disease
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 04/23/2021 Causes of death listed on death certificate: 1) End Stage Renal Disease 2) Diabetes Type 2 with nephropathy 3) Hypertension 4) Coronary Artery Disease


VAERS ID: 1425907 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-19
Onset:2021-04-15
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, COVID-19, Cardiac arrest, Condition aggravated, Coronary artery disease, Death, Haemodialysis, Nucleic acid test, Polymerase chain reaction
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID 19, AKI needing HD
Preexisting Conditions: CAD
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/5/2021 Causes of death listed on death certificate: 1) cardiac arrest 2) unknown cause Other: COVID 19, CAD, AKI needing HD


VAERS ID: 1425911 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-11
Onset:2021-04-15
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Antigen
CDC Split Type:

Write-up: Death: 04/20/2021 Causes of death listed on death certificate: 1) Covid


VAERS ID: 1425918 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-03
Onset:2021-04-15
   Days after vaccination:71
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arteriosclerosis, COVID-19, Condition aggravated, Death, Dementia, Hypertension, Malnutrition, Nucleic acid test, Peripheral vascular disorder, Pneumonia, Polymerase chain reaction, Squamous cell carcinoma of skin
SMQs:, Neuroleptic malignant syndrome (broad), Dementia (narrow), Noninfectious encephalopathy/delirium (broad), Hypertension (narrow), Eosinophilic pneumonia (broad), Skin malignant tumours (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-31
   Days after onset: 46
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: recent Cove at 19, pneumonia
Preexisting Conditions: atherosclerotic heart disease, peripheral vascular disease, hypertension, dementia, extensive squamous cell carcinoma of skin of scalp, protein calorie malnutrition
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/31/2021 Causes of death listed on death certificate: 1) atherosclerotic heart disease Other: recent Cove at 19, pneumonia, peripheral vascular disease, hypertension, dementia, extensive squamous cell carcinoma of skin of scalp, protein calorie malnutrition


VAERS ID: 1425926 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-30
Onset:2021-04-16
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021B21A / 2 - / -

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Cardiac failure congestive, Condition aggravated, Death, End stage renal disease, Hypertension, Nucleic acid test, Sarcoidosis, Sepsis
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (narrow), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-07
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19 sepsis
Preexisting Conditions: Sarcoidosis End stage renal disease Hypertension Congestive heart failure
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death: 5/7/2021 Causes of death listed on death certificate: 1) COVID-19 2) Sepsis 3) Sarcoidosis 4) End stage renal disease Other: Hypertension, Congestive heart failure


VAERS ID: 1426130 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-18
Onset:2021-04-17
   Days after vaccination:58
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chronic obstructive pulmonary disease, Condition aggravated, Death, Nucleic acid test, Polymerase chain reaction
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-30
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid Pneumonia
Preexisting Conditions: Chronic obstructive pulmonary disease, unspecified
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 4/30/2021 Causes of death listed on death certificate: 1) Covid Pneumonia 2) Chronic obstructive pulmonary disease, unspecified Other: none


VAERS ID: 1426131 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-21
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Asthma, Condition aggravated, Pyrexia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nasacort allergy, cetiriine hydrochloride, prednisone, anoro ellipta, albuterol
Current Illness: asthma
Preexisting Conditions: Chronic Obstructive pulmonary disease, Chronic Sinusitis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: mild fever, asthma flare-ups


VAERS ID: 1426460 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-08
Onset:2021-04-25
   Days after vaccination:76
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, Asthenia, Atrial fibrillation, COVID-19 pneumonia, Cardiac failure acute, Death, Depression, Dysphagia, Hypertension, Left ventricular failure, Malnutrition, Nucleic acid test, Polymerase chain reaction, Toxic encephalopathy, Type 2 diabetes mellitus
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypertension (narrow), Cardiomyopathy (broad), Depression (excl suicide and self injury) (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid 19 pneumonia Acute toxic encephalopathy
Preexisting Conditions: Acute on chronic diastolic heart failure Atrial fibrillation Hypertension Type 2 diabetes Esophageal dysphagia Debility Depression Moderate malnutrition.
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death: 5/3/2021 Causes of death listed on death certificate: -1) Acute hypoxic respiratory failure 2) Acute on chronic diastolic heart failure 3) Atrial fibrillation 4) Covid 19 pneumonia Other: Hypertension. Acute toxic encephalopathy. Type 2 diabetes. Esophageal dysphagia. Debility. Depression. Moderate malnutrition.


VAERS ID: 1427108 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-02-24
Onset:2021-03-16
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes mellitus, heart disease
Preexisting Conditions: Diabetes mellitus, heart disease, immune suppressed, kidney transplant 5 years prior
Allergies:
Diagnostic Lab Data: Positive COVID-19 PCR test collected 3/19, another positive COVID-19 PCR collected 3/22
CDC Split Type:

Write-up: COVID symptoms began 3/16, positive test 3/19, hospital admission 3/22, death 4/1


VAERS ID: 1427367 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-04-30
Onset:2021-06-05
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21-2A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: A friend of the patient called us today to inform us that the patient had recently passed away from a brain aneurysm. The friend asked it it were possible that this occurrence was somehow related to patient receiving his covid vaccination. The friend did not have a lot of information about the occurrence; he only stated that the patient''s brain aneurysm was about 6 weeks after his 2nd dose of the covid vaccine. Patient was not a regular patient of ours so we have no additional medical history for him. We administered his first Moderna vaccine on 4-2-2021, and he returned for his second dose on 4-30-2021. I assured the friend I would report this to VAERS and thanked him for reaching out to us on behalf of patient.


VAERS ID: 1427402 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: California  
Vaccinated:2021-06-23
Onset:2021-06-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025C21A / 2 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Death, Dyspnoea, Injection site pain
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-24
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol, zolpidem, sertraline, amlodipine Methamphetamine user
Current Illness:
Preexisting Conditions: Hypertensive and atherosclerotic cardiovascular disease, chronic methamphetamine use, pulmonary emphysema, anxiety disorder
Allergies: Not known
Diagnostic Lab Data:
CDC Split Type:

Write-up: 6/23/2021 - pain at injection site, shortness of breath 6/24 /2021 - found dead in bed at 7AM


VAERS ID: 1427448 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-05-17
Onset:2021-06-15
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: listed in chart are OTC tylenol as needed and meclizine for vertigo
Current Illness: Dizzyness and vertigo
Preexisting Conditions: not listed in chart
Allergies: Not listed in medical chart or history
Diagnostic Lab Data: n/a sudden death
CDC Split Type:

Write-up: Notified on 6/16 /2021 patient died. Death by PE 1 month after prime dose of Moderna-since unexpected- reported to VAERS


VAERS ID: 1427475 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   Days after onset: 98
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized within 60 days of receiving a COVID vaccine series and later died


VAERS ID: 1427795 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2021-01-28
Onset:2021-04-24
   Days after vaccination:86
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Acute respiratory failure, COVID-19, COVID-19 pneumonia, Death, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Cancer, diabetes, hypothyroidism, hypertension
Preexisting Conditions: Cancer, diabetes, hypothyroidism, hypertension
Allergies:
Diagnostic Lab Data: COVID-19 PCR positive test collected 4/16/2021
CDC Split Type:

Write-up: Died 4/24. Immediate cause of death acute hypoxic respiratory failure, underlying cause COVID-19 associated respiratory distress syndrome and COVID-19 viral pneumonia


VAERS ID: 1427845 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-30
Onset:2021-05-24
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospice patient was hospitalized and died within 60 days of receiving a COVID vaccine series


VAERS ID: 1427870 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2021-03-19
Onset:2021-05-03
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19 pneumonia, Death, Pneumonia viral, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-18
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes mellitus, rheumatoid arthritis, chronic immunosuppression
Preexisting Conditions: Diabetes mellitus, rheumatoid arthritis, chronic immunosuppression
Allergies:
Diagnostic Lab Data: Positive COVID-19 PCR tests collected 5/6 and 5/11/2021
CDC Split Type:

Write-up: COVID-19 symptom onset 5/3, hospital admission 5/11, and death on 5/18/2021. Primary cause of death acute hypoxic respiratory failure, underlying cause COVID-19 viral pneumonia


VAERS ID: 1427998 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-05-21
Onset:2021-05-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / UNK AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Heart rate increased
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: insulin, lipitor, not sure what else
Current Illness: Type 1 Diabetes; hospitalized May 16-18 acute ketoacidosis
Preexisting Conditions: Type 1 Diabetes
Allergies: don''t know of any
Diagnostic Lab Data: The final autopsy has not yet been completed, and I don''t know if they''re even checking for Covid-19 vaccine reaction.
CDC Split Type:

Write-up: Patients appointment was either 2:15 or 2:30. His Apple watch recorded it''s last heart beat reading at 3:15 pm, 05/21/2021, within an hour after receiving his second Moderna Covid-19. His heart rate increased rapidly from 3:00 to 3:15, reading 104 - 106 - 108 - 116 bpm. I can provide a photo of these last four readings if you need them. I don''t know other symptoms. His body was found by police who were called for a well-check three days later, 05/24/2021. Patient died unattended, at home, alone. I only know for sure the vaccine was administered at a Target store near his home. Patient texted me at 2:48pm saying that Target gave him a $5 coupon for getting his vaccine, and he was going to use it to buy Tylenol.


VAERS ID: 1428029 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-06-23
Onset:2021-06-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009D21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: Flagyl, Quinolones
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: N/A -- patient was perfectly fine during wait time


VAERS ID: 1428887 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-04-30
Onset:2021-05-11
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / 1 UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Intracranial aneurysm, Life support, Resuscitation
SMQs:, Acute central respiratory depression (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-21
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies: no known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Brain Aneurysm on May 11, 2021, Revived and kept alive on machines until taken off life support and subsequently died on May 21, 2021


VAERS ID: 1428895 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Anticoagulant therapy, Asthenia, Atrioventricular block, Death, Dysstasia, Fall, Haemorrhage urinary tract, Hypotension, Loss of consciousness, Myocardial infarction, Pneumonia, Stent placement, Ventricular tachycardia
SMQs:, Torsade de pointes/QT prolongation (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Flu vaccine 2015, developed pneumonia
Other Medications: Levothyroxine 0.075 mg 1 every morning 2 hours before a meal (also binds to coffee) Ecitalopram 5 mg 1 every morning Donepazil Hcl 5 mg 1 every morning Carbidopa/Levodopa 25/100 mg 4 times per day (7am-11am-3pm-7p) Benazapril 20 mg 1 every
Current Illness:
Preexisting Conditions: Parkinson''s
Allergies: COQ10- nosebleeds Glycopyrrolate ? hives/Rash No Known food allergies
Diagnostic Lab Data: Feb 10th to March 9th he had numerous tests at two hospitals.
CDC Split Type:

Write-up: Feb 8th 2nd vaccination. Next day lost consciousness, fell no injuries. Following day Feb 10th weak and could not stand, BP low, Dr sent him via ambulance. EMS identified him having a heart attack that started Feb 9th. He had no cardiac history He was hospitalized for a sudden blockage, had a vtach episode, did not lose consciousness, one stent placement, had a 2nd vtach episode and did lose consciousness. Placed on blood thinner, within a few days had uncontrolled urinary bleeding, catheter to irrigate, changed blood thinners and did not stop. Continued weakness and decline. Then developed pneumonia the following week. Placed on antibiotics, oxygen 2-7 L/nc. Went to rehab, back and forth to hospital. Came home twice, once Feb 14th for 24 hours, then 2nd time March 9 (his birthday) for his final 2 weeks t home where I cared for him until he passed March 21st. On 4L/NC, did not have catheter, bleeding had stopped.


VAERS ID: 1429240 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-05-19
Onset:2021-05-27
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007C21A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dysarthria, Lethargy
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Back surgery (History of multiple back surgeries including a rod placement.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Death; Dysarthria; Lethargy; This case was received via FDA VAERS (Reference number: 1358542) on 15-Jun-2021 and was forwarded to Moderna on 15-Jun-2021. This regulatory authority case was reported by an other health care professional and describes the occurrence of DEATH (Death), DYSARTHRIA (Dysarthria) and LETHARGY (Lethargy) in a 64-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 007C21A) for COVID-19 vaccination. The patient''s past medical history included Back surgery (History of multiple back surgeries including a rod placement.). On 19-May-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 27-May-2021, the patient experienced DEATH (Death) (seriousness criteria death and medically significant), DYSARTHRIA (Dysarthria) (seriousness criterion death) and LETHARGY (Lethargy) (seriousness criterion death). The patient died on 27-May-2021. The cause of death was not reported. An autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medications were not provided. Treatment information was not reported. On 27 May 2021, autopsy was performed. As per the spouse, the autopsy results were pending. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.Very limited information regarding the events have been provided at this time.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.Very limited information regarding the events have been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1429643 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-01
Onset:2021-02-01
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident, Death
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: She had been treated for liver cancer
Current Illness:
Preexisting Conditions: COPD OSTEOPOROSIS
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Lethal stroke


VAERS ID: 1429713 (history)  
Form: Version 2.0  
Age: 30.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-06-13
Onset:2021-06-18
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050C21A / 2 RA / -

Administered by: Private       Purchased by: ?
Symptoms: Brain oedema, Death, Intensive care, Malaise, Mechanical ventilation, Organ failure, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: No
Current Illness:
Preexisting Conditions: Ulcerative colitis, bipolar, advanced degenerative arthr
Allergies: No
Diagnostic Lab Data: June 18 + 19 2021
CDC Split Type:

Write-up: My son had been complaining of racing heart and became a week after the first dose of Moderna then started vomiting once or twice a week thereafter I tried to get him to go the doctor but he kept saying he was ok. He said he feels like something was wrong but didn?t know what. He received his second dose of moderna 6/13/2021, 5 days later on 6/18/2021 he didn?t feel well laid down around 9 pm was checked on at 9:21 he was unresponsive no heart beat no breathing 911 was called. They resuscitated him after 45 minutes then he was transported to hospital then to medical center. he was in ICU on a ventilator unresponsive brain swollen , totally unresponsive and organs shutting down. He passed away 9:45 pm June 19


VAERS ID: 1429777 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-03-17
Onset:2021-03-26
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-06-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coumadin DM medications
Current Illness:
Preexisting Conditions: Diabetes A fib HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found dead 9 days after vaccine


VAERS ID: 1430452 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-05-27
Onset:2021-05-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Death, Diarrhoea, Laboratory test, Pain in extremity, Pyrexia, Sepsis, Urine analysis, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-06-11
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: None known
Preexisting Conditions: none known
Allergies: Penicillin
Diagnostic Lab Data: Check patient medical records from hospital. Multitude of blood, urine, and other tests performed.
CDC Split Type:

Write-up: Fever, pain in thigh, vomiting, diarrhea, sepsis, eventually died two weeks later. Time of death 6-11-21 1am


VAERS ID: 1430563 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-03-15
Onset:2021-04-05
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Decreased appetite, Dyspnoea, Fatigue, Headache, Loss of consciousness, Nausea, Pain, Thrombotic thrombocytopenic purpura
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Renovascular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Mild Asthma
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On April 2, 2021, person went to the ED at 10:15 AM, where she complained of shortness of breath, fatigue, mild headache and nausea. Patient symptoms were going on for about 3 days. She also reported feeling a bit achy and decreased appetite. She was treated and discharged home the same day. It was later reported by a family member that this person was found unconscious on floor of her bedroom by family members and taken to hospital where she passed away. It was reported hat Doctors were thinking that this was caused by a rare blood disorder (Thrombotic thrombocytopenic purpura, a disease which causes small blood clots and interrupts the blood''s ability to deliver oxygen properly).


VAERS ID: 1430883 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-21
Onset:2021-05-02
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B21A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Angina unstable, Back pain, Cardiac arrest, Death, Gait inability
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Dystonia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-24
   Days after onset: 53
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to the ED on 5/2/2021 for acute back pain, unable to ambulate, unstable angina, NSTEMI and was subsequently hospitalized. Patient received second dose of vaccine on 5/24/2021. On 6/24/2021 he presented to the ED in cardiac arrest and did expire. These visits were within 6 weeks of receiving COVID vaccinations.


VAERS ID: 1430978 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-31
Onset:2021-04-04
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dizziness, Nausea, Pyrexia
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Received COVID-19 monoclonal antibodies 02/2021
Current Illness: tested positive for COVID-19 on 01/28/2021 via PCR testing
Preexisting Conditions: Obesity
Allergies:
Diagnostic Lab Data: 01/28/2021 COVID-19 PCR test positive
CDC Split Type:

Write-up: 03/31/2021 received 1st dose of Moderna COVID-19 vaccine 04/01/2021 104 F fever, dizziness, nausea 04/03/2021 symptoms subsided 04/04/2021 case expired as a result of undetermined natural causes per medical examiner final report


VAERS ID: 1430991 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-19
Onset:2021-03-24
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Fall, Generalised tonic-clonic seizure, Malaise, Mental status changes, Muscular weakness, Speech disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Systemic lupus erythematosus (broad), Dementia (broad), Convulsions (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-11
   Days after onset: 79
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was a 77 year old, resident, past medical history of dementia, hypertension, schizophrenia, hyperlipidemia, Parkinson''s disease. Patient presented to the ED with altered mental status and a potential seizure. In the morning of 3/24, patient reportedly had an episode of seizure that lasted 30 seconds, generalized tonic/clonic. It is unknown if she fell or hit her head. Per manager, patient is following Neurology, recent work up for possible syncopal month ago. Patient received her 2nd dose of Moderna Vaccine recently on 3/19. At baseline patient is independent, ambulates by her self. Patient has been ill after receiving a COVID vaccine last week. Patient has progressive weakness of the bilateral lower extremities and progressive difficulties with talking , had had multiple falls.


VAERS ID: 1431080 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-23
Onset:2021-05-28
   Days after vaccination:66
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Death, Peripheral swelling, Pneumonia, Upper gastrointestinal haemorrhage
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal haemorrhage (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-21
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death LEG SWELLING N17.9 - Acute kidney failure, unspecified J18.9 - Pneumonia, unspecified organism K92.2 - GI bleed K92.2 - Upper GI bleed


VAERS ID: 1431110 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-25
Onset:2021-05-23
   Days after vaccination:87
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Gastrointestinal haemorrhage, Pneumonia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-17
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Gastrointestinal hemorrhage, unspecified Pneumonia


VAERS ID: 1431133 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-18
Onset:2021-04-30
   Days after vaccination:71
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Death, Hyponatraemia, Hypoosmolar state, Pneumonia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-24
   Days after onset: 55
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death J18.9 - Pneumonia, unspecified organism E87.1 - Hypo-osmolality and hyponatremia N17.9 - Acute kidney failure, unspecified


VAERS ID: 1431162 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-29
Onset:2021-06-15
   Days after vaccination:47
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B23A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-18
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death N17.9 - Acute kidney injury (CMS/HCC)


VAERS ID: 1431167 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-17
Onset:2021-05-17
   Days after vaccination:89
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 07L20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 33
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death J18.9 - Pneumonia of both lower lobes due to infectious organism


VAERS ID: 1431198 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-06
Onset:2021-03-28
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Death, Hyponatraemia, Hypoosmolar state
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-06
   Days after onset: 70
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death E87.1 - Hypo-osmolality and hyponatremia N17.9 - Acute kidney failure, unspecified


VAERS ID: 1431211 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-04-09
Onset:2021-04-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 2 AR / SYR

Administered by: Other       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: cefTRIAXone (ROCEPHIN) 2,000mg 1 dose by intraveous injection every 24 hours vancomycin (VANCOCIN) 1,250mg 1 dose by intraveous injection every 12 hours Victoza 0.6mg subcutaneous injection daily HYDROcodone-acetaminophen 5-325mg as needed
Current Illness: Infection in foot Diabetes
Preexisting Conditions: Diabetes
Allergies: Penicillamine Penicillins Sulfa (Sulfonamide Antibiotics) Pollen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Death


VAERS ID: 1431215 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-06-02
   Days after vaccination:96
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-15
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death N17.9 - AKI (acute kidney injury)


VAERS ID: 1431244 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Cough, Death, Inflammatory marker increased, Pyrexia, Rhinorrhoea, Upper gastrointestinal haemorrhage
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal haemorrhage (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Chronic Leukemia, High Blood Preasure
Allergies:
Diagnostic Lab Data: Hospitalized two times
CDC Split Type:

Write-up: started with runny nose, fever, cough. ended in death due to Upper GI Bleed and inflammatory markers very elevated and no explanation why.


VAERS ID: 1431322 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-14
Onset:2021-03-19
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac failure, Cardiac failure congestive, Death, Dyspnoea, Ejection fraction decreased, General physical health deterioration, Renal impairment, Thoracic cavity drainage, Transient ischaemic attack
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Ischaemic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-05-31
   Days after onset: 73
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: had a renal artery blockage/ stent placement in 2004
Allergies:
Diagnostic Lab Data: Many during admission to hospital 3/36/2021 through 4/5/2021. Full evaluation of lungs, heart, renal system, abdomen, etc. Lungs drained by chest tube. Pleur-Ex drains placed to both lung areas for palliative care at home.
CDC Split Type:

Write-up: Patient began experiencing Shortness of Breath, which increased until he had to be transported to the ER on 3/26/2021. He was diagnosed with severe Congestive Heart Failure, with an injection fraction of 15% and kidney function below 30%. He was released to hospice care 4/5/2021 with Pleur-Ex drains to both lung areas. He continued to get worse, including TIAs, until he died on 5/31/2021.


VAERS ID: 1431331 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-06-26
Onset:2021-06-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: DM, HTN, Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received second COVID vaccine on 2/3/2021. Was admitted to Medical Center on 6/15/21 for generalized weakness and tested positive for COVID 19 on 6/15/2021. Patient was also positive for COVID 19 in November 2020. Patient expired on 6/26/2021 while hospitalized.


VAERS ID: 1431351 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-09
Onset:2021-03-05
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death, Dyspnoea, Myalgia, Pneumonia, SARS-CoV-2 test positive, Taste disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Taste and smell disorders (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNK
Current Illness: UNK
Preexisting Conditions: Chronic heart disease, chronic kidney disease, diabetes mellitus, high blood pressure
Allergies: UNK
Diagnostic Lab Data: COVID-19 positive 3/7/2021
CDC Split Type:

Write-up: 3/7/2021: dysregulated taste, dyspnea, Myalgia, pneumonia, hospitalized, treated but died


VAERS ID: 1431502 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-02-04
Onset:2021-06-26
   Days after vaccination:142
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Vaccine breakthrough infection
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: interstitial lung disease along with multiple heart issues
Preexisting Conditions: interstitial lung disease along with multiple heart issues
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient died of complications due to COIVD-19 illness, which was 4 months after receiving his second dose of vaccine. He was a breakthrough case that died with full vaccination status for COIVD-19. No one is indicating that the vaccine had anything to do with this persons'' death.


VAERS ID: 1431530 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-25
Onset:2021-05-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 049C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine/benazepril 10/40mg, carvedilol 25mg, aspirin 81mg, fenofibrate 145mg, fluticasone 50mcg nasal spray, humalog mix 75/25, hydroxyzine 25mg
Current Illness: no illnesses reported
Preexisting Conditions: diabetes , high blood pressure
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Pt. got shot on 5/25 but started feeling real bad arm pain on day 2. The pain got worse in arm and patient reached out to pharmacy questioning arm pain to which he was told it was an expected side effect of the shot but because he was still in pain he made an appointment with his doctor on the coming Monday, but unfortunately, he passed away on Sunday 5/30/21 and was found by neighbors. Brother wants to report death because he took the vaccine


VAERS ID: 1431733 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Agitation, Asthenia, Biliary colic, Blood test abnormal, Cardiac failure congestive, Death, Diagnostic procedure, Drainage, Dyspnoea, Hallucination, Hepatic pain, Hyperventilation, Illness, Laboratory test, Pleural effusion, Pneumonia, Renal impairment, Sleep disorder, Ventricular assist device insertion
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (narrow), Gallbladder related disorders (narrow), Biliary tract disorders (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 84
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 32 days
   Extended hospital stay? No
Previous Vaccinations: The first vaccine. Other than that, no.
Other Medications: He was taking normal supplements to maintain health for his age.
Current Illness: None. He felt bad (flu like symptoms) after the first shot (2/27/21) for about two weeks but recovered.
Preexisting Conditions: He had a heart attack in 2006 and bypass surgery. Over the years he had stents put in but didn''t have problems - worked out with a trainer regularly, cared for his 5 year old granddaughter after school, maintained a property in the mountains - no problem.
Allergies: Unknown
Diagnostic Lab Data: You name it, they did it. You have the three hospitals and they probably have reams of test results. They did not suggest that this was an adverse reaction to the vaccine nor did they indicate it was natural - we are the ones who chronicled the series of events and felt compelled to report.
CDC Split Type:

Write-up: I am filing this on behalf of my sister, who feels it needs to be reported but she is too grief-stricken to do this herself. The morning after the second shot, my sister texted that her husband was up at least 10 times during the night, and five times the next night. He was agitated and hallucinating (swatting at bugs that weren''t there.) For the next four weeks he had progressively more difficult breathing, and on 4/28 a liter of fluid was drained from his chest. He continued to have difficulty breathing and was taken by ambulance to Hospital on May 2 where they again drained his chest and diagnosed him with pneumonia. A nurse told him they were seeing a number of cases of fluid around the lungs (his fluid was around the lungs, not in them) after COVID vaccines. He was sent home May 4 and commented that it was strange his cardiologist hadn''t visited. Almost immediately he was experiencing liver and gall bladder pain, even though tests for those showed the two organs were healthy. On May 8 my sister said patient woke up hyperventilating, which also became more frequent. On the 9th his daughter told me the labs were not trending well, and on May 10 he saw his cardiologist. He diagnosed him with congestive heart failure and got him an appointment at the Heart Hospital on May 17 - he explained congestive heart failure is scary but can be managed through programs at the heart hospital. He began sleeping outside because it made it easier to breathe. On May 15 he was advised to go to the ER/Hospital for tests the heart hospital would need and, once there, they discovered his kidneys weren''t functioning and he was admitted immediately. He spent 17 days at Hospital- if the kidneys improved, the heart got worse. If the heart improved, the kidneys failed. He was released on June 2. On June 7 my brother took him to get blood work done - Patient was too weak to get in and out of the car by himself. The blood work came back bad, and on June 8 he was admitted to the Heart Hospital. On June 10 he was transferred to the Regional Community Hospital to be closer to his cardiologist. From there he continued to decline, and the doctors wanted to do surgery for a LVAD but couldn''t. To help him get stronger, he had an impeller put in by catheter on June 19 and died that night. His own cardiologist said congestive heart failure is manageable. The symptoms started the night of the second vaccine and his illness wasn''t gradual - he went off a cliff. With all the heart problems appearing in males, we don''t think this was coincidence.


VAERS ID: 1432196 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-19
Onset:2021-04-20
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A/039B21A / UNK - / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Influenza like illness, Lung disorder, Mechanical ventilation, Oxygen saturation decreased, Paraesthesia, Renal failure, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-14
   Days after onset: 55
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetic, high blood pressure, blind
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day she received the second dose she started with flu like symptoms. She also had tingling hands and feet her condition did not get better and was rushed to the ER. She was there for 4 days and sent to a long term facility where her condition worsen. She started having breathing issues went back to the ER with chronic breathing complications. At the hospital she had low oxygen level, lung complications, kidney failure and went into cardiac arrest. She was resuscitate and put on a ventilator for 3 days. She started breathing on her own and was taken off the machines. She was sent home a few days later and nine days later went into cardiac arrest again and this time did not make it.


VAERS ID: 1432736 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-06-01
Onset:2021-06-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Fatigue
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Chronic kidney disease (On HD)
Preexisting Conditions: Medical History/Concurrent Conditions: Hemodialysis
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Death; Cardiac arrest; Fatigue; This case was received on 15-Jun-2021 and was forwarded to Moderna on 15-Jun-2021. This regulatory authority case was reported by an other health care professional and describes the occurrence of DEATH (Death), CARDIAC ARREST (Cardiac arrest) and FATIGUE (Fatigue) in a 73-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included Hemodialysis. Concurrent medical conditions included Chronic kidney disease (On HD). On 01-Jun-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 02-Jun-2021, the patient experienced DEATH (Death) (seriousness criteria death and medically significant), CARDIAC ARREST (Cardiac arrest) (seriousness criteria death and medically significant) and FATIGUE (Fatigue) (seriousness criterion death). The patient died on 02-Jun-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. No treatment/concomitant medications were reported. Very limited information regarding these events has been provided at this time. No further follow-up information is expected.; Sender''s Comments: Very limited information regarding these events has been provided at this time. No further follow-up information is expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1432862 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-04
Onset:2021-03-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Metastases to bone, Metastases to central nervous system, Metastases to lung, Metastases to pancreas, Small cell carcinoma, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-10
   Days after onset: 59
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Small cell carcinoma; cancer of pancreas / metastasized; Metastases to lungs; Metastates to bone; Metastases to brain; Wheezing; This spontaneous case was reported by a consumer and describes the occurrence of SMALL CELL CARCINOMA (Small cell carcinoma), METASTASES TO PANCREAS (cancer of pancreas / metastasized), METASTASES TO LUNG (Metastases to lungs), METASTASES TO BONE (Metastates to bone), METASTASES TO CENTRAL NERVOUS SYSTEM (Metastases to brain) and WHEEZING (Wheezing) in a 70-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On 04-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 01-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 11-Mar-2021, the patient experienced WHEEZING (Wheezing) (seriousness criterion hospitalization). On an unknown date, the patient experienced SMALL CELL CARCINOMA (Small cell carcinoma) (seriousness criteria death, hospitalization and medically significant), METASTASES TO PANCREAS (cancer of pancreas / metastasized) (seriousness criteria death, hospitalization and medically significant), METASTASES TO LUNG (Metastases to lungs) (seriousness criteria death, hospitalization and medically significant), METASTASES TO BONE (Metastates to bone) (seriousness criteria death, hospitalization and medically significant) and METASTASES TO CENTRAL NERVOUS SYSTEM (Metastases to brain) (seriousness criteria death, hospitalization and medically significant). The patient was hospitalized from 25-Apr-2021 to 10-May-2021 due to METASTASES TO BONE, METASTASES TO CENTRAL NERVOUS SYSTEM, METASTASES TO LUNG, METASTASES TO PANCREAS, SMALL CELL CARCINOMA and WHEEZING. The patient died on 10-May-2021. The reported cause of death was Cancer of lung, Bone cancer, Metastases to brain, Pancreas cancer and Small cell carcinoma. It is unknown if an autopsy was performed. At the time of death, WHEEZING (Wheezing) outcome was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Concomitant Product use was not provided. LABORATORY / DIAGNOSTIC TEST: Ultrasound, computerized tomography (CAT) scan and numerous other tests; result was not provided. Treatment information was not provided. Action taken with mRNA-1273 (Moderna COVID-19 Vaccine) in response to the event was not applicable. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: cancer of lung; bone cancer; metastases to brain; pancreas cancer; small cell carcinoma


VAERS ID: 1432866 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Florida  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Her son has died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Her son has died) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No relevant concomitant medications were reported. No treatment information was provided. This is a case of death in a male subject who died after receiving first dose of vaccine Very limited information has been provided at this time.; Sender''s Comments: This is a case of death in a male subject who died after receiving first dose of vaccine Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1433471 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-04
Onset:2021-05-08
   Days after vaccination:93
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Chronic Lymphocetic Leukemia - had blood infusions last summer, last one was on July 7
Preexisting Conditions: Chronic heart disease Chronic kidney disease High blood pressure quadruple heart bypass in 2004
Allergies: Unknown
Diagnostic Lab Data: Positive COVID-19 PCR test on 04/30/2021
CDC Split Type: 244693

Write-up: Died of COVID-19 illness on 05/08/2021


VAERS ID: 1433476 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-12
Onset:2021-03-19
   Days after vaccination:66
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Death, Mechanical ventilation, Pneumonia
SMQs:, Interstitial lung disease (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: DM2, HTN, CAD, LUNG DISEASE, HX OF TIA
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PNEMONIA, ARDS, VENT REQUIRED 4 DAYS DOD3/19/21


VAERS ID: 1433495 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-04-14
Onset:2021-04-03
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Gastrointestinal disorder
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: HOSPITALIZED MEDICAL CENTER DOD 4/3/21 COD GASTROINTESTINAL DISEASE


VAERS ID: 1433503 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-29
Onset:2021-03-14
   Days after vaccination:44
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Ativan, GenTeal Tears, Haldol, Roxanol, Triple antibiotic ointment, Aspercreme
Current Illness:
Preexisting Conditions: Hypertension, AFib, CHF, Type 2 diabetes, chronic lymphocytic leukemia
Allergies: Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 03/14/2021


VAERS ID: 1433561 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-28
Onset:2021-03-07
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Alumina-Magnesia-Simethicone, docusate sodium, Dulcolax, Neurontin, Desyrel, Effexor, Miralax
Current Illness:
Preexisting Conditions:
Allergies: Fentanyl, Versed, Aricept, Lopid, Zocor
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 03/07/2021


VAERS ID: 1433741 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-06-25
Onset:2021-06-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: xarelto, advair, albuterol
Current Illness: possible DVT
Preexisting Conditions: hypercoagulable state (multiple DVT/PE)
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found unresponsive at home, CPR administered by EMS/ER, patient deceased.


VAERS ID: 1433744 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-04-15
Onset:2021-05-02
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001C21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Neurontin, Augmentin, Aricept, Ultram, Lantus, Tylenol, Deltasone, Protonix, Arava, Calcium carbonate, zyloprim, duo-neb, remeron, multi vitamin, ferate
Current Illness:
Preexisting Conditions:
Allergies: Aspirin, cheese, molds, Na bisulfite- procaine, Statins, sulfa drugs, whey, and environmental
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 05/02/2021.


VAERS ID: 1433776 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-12
Onset:2021-05-03
   Days after vaccination:80
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Aneurysm ruptured, Death, Haemorrhage, Peripheral artery aneurysm
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 5/5/2021 Causes of death listed on death certificate: 1) acute bleeding 2) rupture of internal iliac aneurysm


VAERS ID: 1433783 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-18
Onset:2021-05-07
   Days after vaccination:78
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Condition aggravated, Death, Diabetes mellitus, SARS-CoV-2 test positive, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid19 pneumonia
Preexisting Conditions: Ventricular fibrillation Diabetes
Allergies:
Diagnostic Lab Data: Antigen
CDC Split Type:

Write-up: Death 5/7/2021 Causes of death listed on death certificate: 1) Ventricular fibrillation 2) Covid19 pneumonia Other: Diabetes


VAERS ID: 1433788 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-01
Onset:2021-05-10
   Days after vaccination:98
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Coronary artery disease, Death, Hypertension, Nucleic acid test, Pneumonia, SARS-CoV-2 test positive, Type 2 diabetes mellitus
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: pneumonia COVID 19 3.
Preexisting Conditions: coronary artery disease hypertensin Non insulin dependant diabetes
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/29/2021 Causes of death listed on death certificate: 1. pneumonia 2. COVID 19 3. coronary artery disease, hypertensin, Non insulin dependant diabetes


VAERS ID: 1433796 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-04
Onset:2021-04-28
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Kenalog, Lasix, Generlac, Protonix, Aldactone, Actigall, Cardura, Vitamin D3, Cerave, aspirin, metoprolol
Current Illness:
Preexisting Conditions:
Allergies: Ace Inhibitors, hydralazine, omeprazole, simvastatin, actigall
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 04/28/2021


VAERS ID: 1433815 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-16
Onset:2021-04-18
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Miacalcin, cyanocobalamin, Claritin, milk of magnesia, namenda, desyrel, vitamin D3, flonase, melatonin, voltaren, xylocaine, ativan, zofran, oxycodone, miralax, depakote
Current Illness:
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 04/18/2021.


VAERS ID: 1433819 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-24
Onset:2021-05-11
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Condition aggravated, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-06
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: 1) covid pneumonia
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Antigen
CDC Split Type:

Write-up: Death 6/6/2021 Causes of death listed on death certificate: 1) covid pneumonia


VAERS ID: 1433851 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-03
Onset:2021-05-03
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tessalon, Vitamin B12, Fortamet, Spiriva, lasix, cardizem, Klor-Con, Flonase, Eucerin, Miralax, requip, xarelto, acetaminophen, albuterol, atorvastatin, loratadine, losartan
Current Illness:
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away on 05/03/2021.


VAERS ID: 1433939 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-06-15
Onset:2021-06-19
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053C21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-01
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide 25mg Basaglar KwikPen Suboxone 8mg-2mg film Aspirin 81mg Doxepin 10mg Chlorpromazine 100mg Olanzapine 10mg Keppra 750mg Atorvastatin 40mg Admelog Amitriptyline 50mg Gabapentin 800mg Lisinopril 40mg Metformin 1000mg Ci
Current Illness: Suspected drug overdose 6/2- left ER AMA
Preexisting Conditions: Type 2 Diabetes Hyperlipidemia Hypertension GERD Seizure disorder
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received Moderna #1 on 4/20/21 and Moderna #2 on 6/15/21. Our office was notified on 6/19/21 that this patient was found deceased and appeared to have passed away several days prior due to level of decomposition. The cause of death is unknown at this time and is being evaluated by Medical Examiner due to recent Covid vaccination and recent drug overdose on 6/2/21. No foul play suspected.


VAERS ID: 1435925 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Product contamination, Pyrexia, Septic shock
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Fatal fevers; Septic shock; Product contamination; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a non-health professional and describes the occurrence of PYREXIA (Fatal fevers), SEPTIC SHOCK (Septic shock) and PRODUCT CONTAMINATION (Product contamination) in an elderly patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) at an unspecified dose. On an unknown date, the patient experienced PYREXIA (Fatal fevers) (seriousness criterion death), SEPTIC SHOCK (Septic shock) (seriousness criteria death and medically significant) and PRODUCT CONTAMINATION (Product contamination) (seriousness criterion death). The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant product use was not provided. 104 Patients received the vaccine. Treatment information was not provided. Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1435934 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-08
Onset:2021-01-16
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebral haemorrhage, Cerebrovascular accident, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: She had a non traumatic intracerebral hemorrhage; Never regained consciousness after the stroke/unresponsiveness; Stroke; This spontaneous case was reported by a patient family member or friend and describes the occurrence of CEREBRAL HAEMORRHAGE (She had a non traumatic intracerebral hemorrhage), LOSS OF CONSCIOUSNESS (Never regained consciousness after the stroke/unresponsiveness) and CEREBROVASCULAR ACCIDENT (Stroke) in an 82-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included Type 2 diabetes mellitus on 21-Jan-2021. On 08-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 16-Jan-2021, the patient experienced CEREBRAL HAEMORRHAGE (She had a non traumatic intracerebral hemorrhage) (seriousness criteria death, hospitalization and medically significant), LOSS OF CONSCIOUSNESS (Never regained consciousness after the stroke/unresponsiveness) (seriousness criteria death, hospitalization and medically significant) and CEREBROVASCULAR ACCIDENT (Stroke) (seriousness criteria death, hospitalization and medically significant). The patient died on 21-Jan-2021. The cause of death was not reported. It is unknown if an autopsy was performed. The concomitant medications include unspecified medications for diabetes and low pressure. Reporter further explained the event as non traumatic intracerebral hemorrhage. Patient was hospitalized for some days and died one or two days after coming back to home. The treatment information was not provided. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Company Comment Very limited information regarding this events has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1435953 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Death; This spontaneous case was reported by a non-health professional and describes the occurrence of DEATH (Death) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1437053 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-05
Onset:2021-04-02
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Chills, Confusional state, Fatigue, Headache, Influenza like illness, Injection site bruising, Injection site erythema, Injection site pain, Injection site pruritus, Injection site swelling, Lethargy, Pain, Pyrexia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Site: Bruising at Injection Site-Mild, Site: Itching at Injection Site-Mild, Site: Pain at Injection Site-Mild, Site: Redness at Injection Site-Mild, Site: Swelling at Injection Site-Mild, Systemic: Body Aches Generalized-Severe, Systemic: Chills-Severe, Systemic: Confusion-Severe, Systemic: Exhaustion / Lethargy-Severe, Systemic: Fever-Severe, Systemic: severe flu-like symptoms-Severe, Systemic: Headache-Severe, Systemic: Weakness-Severe, Additional Details: husband reported patient had severe flu-like sypmtoms


VAERS ID: 1437339 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-23
Onset:2021-05-13
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 5/27/2021 No cause of death provided.


VAERS ID: 1437360 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-23
Onset:2021-03-02
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Nucleic acid test, Polymerase chain reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 3/2/2021


VAERS ID: 1437364 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-05
Onset:2021-04-08
   Days after vaccination:62
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, Coronary artery disease, Death, Failure to thrive, Parkinson's disease, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Neonatal disorders (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-01
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19 infection
Preexisting Conditions: Failure to thrive Parkinson''s Disease Coronary artery disease
Allergies:
Diagnostic Lab Data: Antigen
CDC Split Type:

Write-up: Death 5/1/2021 Causes of death listed on death certificate: 1) Cardiac arrest 2) Failure to thrive 3) Parkinson''s Disease 4) COVID-19 infection 4/2021 Other: Coronary artery disease


VAERS ID: 1437378 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-12
Onset:2021-05-05
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Chronic Kidney Disease
Allergies: Unknown
Diagnostic Lab Data: Positive COVID-19 Antigen test on 04/23/2021
CDC Split Type: 3664158

Write-up: Died of COVID-19 illness on 05/05/2021


VAERS ID: 1437399 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-06
Onset:2021-05-18
   Days after vaccination:73
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cardiac failure, Death, Enterovesical fistula, SARS-CoV-2 test
SMQs:, Cardiac failure (narrow), Gastrointestinal perforation (narrow), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid 19 Pneumonia
Preexisting Conditions: colo-vesical fistular Heart failure chronic uti
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/30/2021 Causes of death listed on death certificate: 1) Covid 19 Pneumonia 2) colo-vesical fistular 3) Heart failure 4) chronic uti


VAERS ID: 1437443 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-13
Onset:2021-05-23
   Days after vaccination:99
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Autoimmune disorder, COVID-19, Cold agglutinins, Death, Haemolytic anaemia, Immunosuppression, Nucleic acid test, Polymerase chain reaction, Rheumatoid arthritis
SMQs:, Haemolytic disorders (narrow), Systemic lupus erythematosus (broad), Arthritis (narrow), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-31
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID 19
Preexisting Conditions: Autoimmune cold-agglutinin hemolytic anemia rheumatoid arthritis chronic immunosuppression
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/31/2021 Causes of death listed on death certificate: 1. Autoimmune cold-agglutinin hemolytic anemia 2. COVID 19 3. rheumatoid arthritis, chronic immunosuppression


VAERS ID: 1437449 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-02
Onset:2021-05-21
   Days after vaccination:108
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Hypertensive heart disease, Left ventricular failure, Nucleic acid test, SARS-CoV-2 test positive
SMQs:, Cardiac failure (narrow), Hypertension (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-30
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Covid-19
Preexisting Conditions: Hypertensive Heart disease with Heart Failure Diastolic
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC Split Type:

Write-up: Death 5/30/2021 Causes of death listed on death certificate: 1) Hypertensive Heart disease with Heart Failure Diastolic Other: Covid-19


VAERS ID: 1437456 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-09
Onset:2021-06-01
   Days after vaccination:112
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Chronic kidney disease, Death, Dysphagia, Hypertension, Oesophageal stenosis, Pneumonia aspiration
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal obstruction (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypertension (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: aspiration pneumonia
Preexisting Conditions: dysphagia esophageal stenosis congestive heart failure hypertension chronic kidney disease stage 3
Allergies:
Diagnostic Lab Data: Antigen
CDC Split Type:

Write-up: Death 6/2/2021 Causes of death listed on death certificate: 1) aspiration pneumonia 2) dysphagia 3) esophageal stenosis Other: congestive heart failure, hypertension, chronic kidney disease stage 3


VAERS ID: 1437464 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-05-26
Onset:2021-05-29
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebral haemorrhage, Chest X-ray, Computerised tomogram head abnormal, Computerised tomogram thorax, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Bayer Low Dose 81 mg 1 by mouth every other day Furosemide 20 mg take one tablet by mouth one time daily Metoprolol Succinate ER 25 mg TAKE ONE TABLET BY MOUTH ONE TIME DAILY for blood pressure Prolia 60 mg/ml 60mg sq at ov every 6month
Current Illness:
Preexisting Conditions: Coronary arteriosclerosis Infiltrating lobular carcinoma of right female breast Benign essential hypertension Goiter Mixed hyperlipidemia Type 2 diabetes mellitus Senile osteoporosis Cerebrovascular disease Atrial fibrillation Anticoagulants Long Term (Current) Use Encounter Cataract Chronic kidney disease stage 3 Degenerative joint disease involving multiple joints Essential hypertension Chronic atrial fibrillation Peripheral venous insufficiency
Allergies: Cephalosporins - generalized body rash
Diagnostic Lab Data: chest xray CT head CT thorax
CDC Split Type:

Write-up: found unresponsive CT of head show large frontotemporal intra-axial hemorrhage


VAERS ID: 1437490 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-05-26
Onset:2021-05-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death, Malaise
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-04
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin M/W/F Metoprolol 50 mg am and 25 mg and night atorvastatin 10mg once daily vitamin D once daily
Current Illness: none- Covid positive at the end of February 2021
Preexisting Conditions: Aortic valve replaced April 2015 and June 2015 ( it got infected and had to be replaced) Notification letter was sent out afterward notifying people that the equipment was faulty and could cause problems
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was feeling in good health prior to receipt of vaccination- Patient reported not feeling well right after receiving the dose; fainted the following day- sought medical care that same day- no issues detected; patient continued to say he did not feel like something was right. Patient died on June 4, 2021- brain bleed - transferred to different hospital-intraparenchymal bleed ---please note- there are NO LOT NUMBERS WRITTEN ON PT VACCINE RECORD!


VAERS ID: 1437505 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-05
Onset:2021-06-28
   Days after vaccination:143
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen, Vit C, Coenzyme Q10, Fish oil, Garlic, Ocuvite-lutein
Current Illness: ARF, CAD, CLL, CVA, anemia, PFO, HTN
Preexisting Conditions: ARF, CAD, CLL, anemia, HTN, CVA, PFO
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 6-28-2021


VAERS ID: 1437580 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-05-01
Onset:2021-05-12
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015B21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003C21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Foaming at mouth, Myocardial infarction, Snoring
SMQs:, Myocardial infarction (narrow), Convulsions (broad), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Generalised convulsive seizures following immunisation (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-21
   Days after onset: 40
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol, Tartrate 100mg, Atorvastatin 40mg, Losartan 100mg, Aspirin 200mg, Vitamin B, Vitamin D, Potassium 99mg.
Current Illness:
Preexisting Conditions: Heart disease, Triple bypass given 2 years ago.
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Was found on the floor, snoring with foam forming out of his mouth. Was sent to the emergency room suffered a heart attack, passed away June 21, 2021.


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