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From the 5/7/2021 release of VAERS data:

Found 4,057 cases where Vaccine is COVID19 and Patient Died



Case Details (Reverse Sorted by Onset Date)

This is page 8 out of 41

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VAERS ID: 1209873 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-03-15
Onset:2021-03-31
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Public       Purchased by: ?
Symptoms: Anal incontinence, Aphasia, Death, Eye pain, Facial paralysis, Gait inability, Haemorrhagic stroke, Headache, Hyperhidrosis, Intensive care
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hearing impairment (broad), Noninfectious diarrhoea (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: I am her brother reporting for her because she died. She was taking a blood thinner, high blood pressure medication, gabepentin, and an antidepressant, I believe.
Current Illness:
Preexisting Conditions: Chronic pain. She had had an ischemic stroke in 2009 (12 years ago), but had almost completely recovered.
Allergies: None
Diagnostic Lab Data: I am unsure what tests and labs were taken while she was hospitalized, but I am sure the records can be retrieved.
CDC Split Type:

Write-up: The day after receiving the first dose of the Pfizer vaccine, she developed a headache behind her right eye that never went away. Then on Wednesday morning, March 31st (two weeks after receiving the first dose), she was found in bed by my mother, unable to walk or talk, her face was drooping, she was very sweaty, and had defecated on herself. My mother called the ambulance. She was transported to Hospital where it was determined she had suffered a massive hemorrhagic stroke. She was immediately transported by ambulance to another Hospital. She spent one day in ICU and then was put on palliative care. She died around 12/N on Friday, April 2nd, two days after the stroke.


VAERS ID: 1215380 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-02-05
Onset:2021-03-31
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: peripheral vascular disease
Preexisting Conditions: cerebrovascular disease wernickes encephalopathy chronic obstructive pulmonary disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: no symptoms


VAERS ID: 1220532 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-03-14
Onset:2021-03-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.


VAERS ID: 1229218 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-31
Onset:2021-03-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Intracranial aneurysm, Life support
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: 2021-04-03
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Meloxicam
Current Illness: none
Preexisting Conditions: Neck pain, Arthritis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mom had a brain aneurysm 45 minutes after receiving her second Covid vaccine on Wednesday, March 31st, 2021. She was rushed to Medical Center. After her CT Scan she was put on Life support that morning. After consulting with Doctors we took her off Life Support at 4:00 pm on Friday April 2nd and she passed away 29 hours later at 9;00 pm on Saturday, April 3rd.


VAERS ID: 1230024 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-18
Onset:2021-03-31
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Death, Dyspnoea, Endotracheal intubation, Hypoxia, Platelet disorder, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: 1. Kidney stones - N20.0 (Primary) 2. Urinary tract infection without hematuria, site unspecified - N39.0 3. Type 2 diabetes mellitus with diabetic chronic kidney disease - E11.22 4. Type 2 diabetes mellitus with other specified complication - E11.69 5. Chronic kidney disease, stage II (mild) - N18.2 6. Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease - I13.0 7. Heart failure, unspecified - I50.9 8. Hyperlipidemia, unspecified - E78.5 9. Atherosclerotic heart disease of native coronary artery without angina pectoris - I25.10 10. Edema, lower extremity - R60.0 11. Chronic obstructive pulmonary disease, unspecified - J44.9 12. Obstructive sleep apnea (adult) (pediatric) - G47.33 13. Peripheral vascular disease, unspecified - I73.9 14. Cardiomyopathy, dilated - I42.0 15. Morbid (severe) obesity due to excess calories - E66.01 16. Nicotine dependence with nicotine-induced disorder - F17.209 17. Bipolar disorder, current episode
Allergies: NKDA
Diagnostic Lab Data: CT of the chest with PE. Nl platelets at arrival. Then decrease
CDC Split Type:

Write-up: Shortness of breath, hypoxia, Pulmonary Embolism, intubation death.


VAERS ID: 1271726 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-31
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9809 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Death within 60 days of vaccination


VAERS ID: 1272012 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-31
Onset:2021-03-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arthralgia, Chills, Headache, Pain in extremity, Sleep disorder, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   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: Losartan 100mg, Hydrochlorothizide 25 mg, Pioglitazone 30mg, Glipepiride 2mg, Rosuvastatin 10mg, Carvedilol 12.5mg
Current Illness:
Preexisting Conditions: Chronic kidney failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Arm became sore at 5:25 pm (03/31/2021) developed chills, could not sleep for shaking, headache and joint pain (03:08 pm on 04/01/2021) ***this is what she texted to me and my other sister and the 03:08 pm text was the last text she had texted***


VAERS ID: 1274456 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-24
Onset:2021-03-31
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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: 2021-04-12
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: received vaccine on 3/24/21 at another site. Was admitted to the hospital thru the ED with worsening shortness of breath.


VAERS ID: 1276416 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-03-31
Submitted: 0000-00-00
Entered: 2021-05-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cerebrovascular accident, Computerised tomogram, Fibrin D dimer, Fibrin D dimer increased, Gastric haemorrhage, Platelet count, SARS-CoV-2 test positive, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (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), Gastrointestinal haemorrhage (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
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? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: EFFEXOR; ALBUTEROL [SALBUTAMOL]; AMLODIPINE
Current Illness: Asthma; Bipolar disorder; Depression; Hypertension
Preexisting Conditions: Comments: No known allergies (NKDA)
Allergies:
Diagnostic Lab Data: Test Date: 202103; Test Name: Fibrin D dimer; Result Unstructured Data: high; Test Name: COVID-19 virus test positive; Result Unstructured Data: positive; Test Name: Platelet count; Result Unstructured Data: 157; Test Name: Platelet count; Result Unstructured Data: 86; Test Name: CAT scan; Result Unstructured Data: focal stroke; Test Name: CT scan; Result Unstructured Data: see comments; Comments: worsening large multi-focal left hemispheric stroke in multiple distributions.
CDC Split Type: USJNJFOC20210444500

Write-up: COVID-19 PNEUMONIA; STOMACH BLEEDING; THROMBOCYTOPENIA; MASSIVE STROKE; FIBRIN D DIMER HIGH; This spontaneous report received from a consumer (daughter of patient) via a Regulatory Authority [VAERS FDA 1218360] and concerned a 79 year old female. The patient''s height, and weight were not reported. The patient''s concurrent conditions included bi-polar, mild asthma, hypertension, and depression. The patient had no allergies and no known drug allergies. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, intramuscular, batch number: 1805020) dose was not reported, 1 in total administered on 30-MAR-2021 to left arm for prophylactic vaccination. Concomitant medications included amlodipine, salbutamol, and venlafaxine hydrochloride. The patient felt poorly after vaccination. The patient presented to emergency room with gastrointestinal upset, diarrhea, nausea, vomiting, fever and cough on unspecified date. The patient was sent home. On 31-MAR-2021, the patient was COVID-19 positive and was admitted to the hospital with Covid-19 pneumonia. The patient was on oxygen via nasal cannula. On 31-MAR-2021, the patient had high fibrin D dimer and patient had a stomach bleeding. The patient was worsening and was admitted to intensive care unit. On unspecified date, the patient developed arm weakness which progressed over days. On unspecified date in 2021, the patient had massive stroke and passed in the morning. The stroke did not show the signs of hemorrhage. The distribution of stroke was multifocal and could suggest thrombus. The patient developed thrombocytopenia in the last 24 hours of life. The initial computerized tomogram (CT) noted one area of focal stroke. The second CT showed worsening large multi-focal left hemispheric stroke in multiple distributions. This was an acute development over the previous CT. On 26-APR-2021, physician reported the radiology report was not clear whether the Cerebroventricular accident (CVA), the patient had experienced was a thrombotic event as the patient had areas on the CT scan that could be old CVAs and in addition the patient had hypertension. The patient developed thrombocytopenia on day 12 while she was treated with heparin. D-dimer was elevated on admission and throughout the hospitalization and the anti- PF4 antibodies were not able to be performed from the sample available. As per the physician, the radiology report was not clear whether the CVA the subject had experienced was a thrombotic event as the subject had areas on the CT scan that could be old CVAs and in addition the subject had a hypertension. The subject develop thrombocytopenia on day 12 while she was treated with heparin. Additional laboratory test included platelet count was 157 and dropped to 86 on unspecified date. The patient was treated with heparin. Laboratory data (dates unspecified) included: Fibrin D dimer (NR: not provided) high. The patient died on unspecified date. It was unknown if an autopsy was performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died of covid-19 pneumonia, massive stroke and thrombocytopenia on an unspecified date, had not recovered stomach bleeding, and fibrin d dimer high. This report was serious (Death, Hospitalization Caused / Prolonged, Other Medically Important Condition, and Life Threatening). Additional information was received from physician on 26-APR-2021 via telephone log from a company employee. The following information was updated and incorporated into the case narrative: reporters added (physician and contact),due diligence updated and physicians statement.; Sender''s Comments: V1: The follow up information in this version is regarding addition of reporters (physician and contact) physicians statement and due diligence. This updated information does not alter the causality of previously reported events. This 79-year-old hypertensive female died from massive stroke after being hospitalized from COVID-19 pneumonia 1 day after receiving Janssen COVID-19 vaccine for the prevention of symptomatic SARS-CoV-2 virus infection. On admission to hospital the patient had positive COVID-19 test. She also had a high fibrin D-dimer throughout the hospitalization and developed a stomach bleeding. Other symptoms included arm weakness that progressed over a couple of days. Initial CT scan noted one area of focal stroke; the second CT scan showed worsening large multi-focal left hemispheric stroke in multiple distributions. Platelet count was initially 157 and dropped to 86 on an unspecified date. The patient was treated with heparin. The event of stroke is confounded by the underlying hypertension and COVID-19 disease; and the event of thrombocytopenia is confounded in COVID-19 infection. The information available precludes a complete and meaningful assessment. However, considering the temporal plausibility and recently evolving theories in the literature about COVID infections and vaccinations, potential vaccine contribution cannot be excluded. Additional information has been requested.; Reported Cause(s) of Death: MASSIVE STROKE; COVID-19 PNEUMONIA; THROMBOCYTOPENIA


VAERS ID: 1289378 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-31
Onset:2021-03-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP6955 / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain, Acute myocardial infarction, Arteriosclerosis, Autopsy, Condition aggravated, Death, Histology abnormal, Hypertension, Insomnia, SARS-CoV-2 test negative, Toxicologic test normal, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, lisinopril, crestor, androgel, ibuprofen prn
Current Illness:
Preexisting Conditions: Hypertensive and atherosclerotic cardiovascular disease, heart failure, status post remote quadruple CABG and endovascular coronary artery stent placement
Allergies: None known
Diagnostic Lab Data: Autopsy was performed on April 2nd. No evidence of anaphylaxis/airway edema was found. No evidence of thrombi. Autopsy confirmed significant pre-existing cardiac disease and histologic exam confirmed acute myocardial infarction. Toxicology was non-contributory. COVID-19 testing performed at the hospital was negative.
CDC Split Type:

Write-up: Patient had second dose of Pfizer vaccine in morning. That afternoon began complaining of abdominal pain with subsequent vomiting (x2) and possible diarrhea. Patient could not sleep that evening . Awoke next morning with continued abdominal pain throughout the day and ultimately was found unresponsive in bed. Transported to hospital where he was pronounced dead. Subsequently autopsy was performed which revealed significant pre-existing hypertensive and atherosclerotic cardiovascular disease with evidence of acute myocardial infarction. There is no clear evidence that this is related to the vaccination, however it is being reported due to potential public health interest and temporal proximity to vaccination.


VAERS ID: 1293409 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-03-18
Onset:2021-03-31
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-05-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine
Current Illness: Hypothyroid
Preexisting Conditions:
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Started feeling sick day of 2nd dose of the Moderna vaccine. never felt good. personal journal entries testify of this. never felt good before she died. Had a massive thrombophlebotic stroke 10 days later causing death.


VAERS ID: 1151915 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-11
Onset:2021-03-30
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Agonal respiration, Agonal rhythm, Cardiac arrest, Central venous catheterisation, Echocardiogram abnormal, Electrocardiogram abnormal, Endotracheal intubation, Hypotension, Pulse absent, Resuscitation, Sinus bradycardia, Syncope, Therapeutic hypothermia, Vital functions abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Disorders of sinus node function (narrow), Conduction defects (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Albuterol sulfate 90mcg/actuation inhaler 2 puffs every 4 hours as needed Hydrochlorothiazide (Microzide) 12.5 mg daily lisinopril (PRINIVIL) 10 mg tablet daily
Current Illness: none
Preexisting Conditions: none
Allergies: No known allergies
Diagnostic Lab Data: see above
CDC Split Type:

Write-up: presents to the ED via EMS in cardiac arrest. EMS report patient was in agonal respiration upon arrival and has had no pulse since 2109. Patient had a syncopal episode on the toilet prior to EMS call. EMS notes they gave patient 4 epinephrine, 1 bicarbonate, and 1 Narcan. Patient arrived with a lucas machine in place and intubated. Patient''s intubation was verified to be a 7.0 ETT and 23 cm at the lip. Cardiac Activity noted in ED at 2150. See nurses notes for times medications were administered. Further history limited due to unstable vital signs. Pt hypotensive, started and maxed on levophed, epinephrine infusions and additional push dose epi given. Right femoral central line placed. Pt began to brady down, was given atropine, ultimately again became pulseless and CPR resumed. After 2 further rounds of ACLS, total down time approached 1 hour without return of pulse. On echo, there were occasional agonal beats, but no organized cardiac activity. EKG and case had been discussed with Dr. Friday and decision was to attempt therapeutic hypothermia prior to second cardiac arrest as EKG showed inferolateral STEMI


VAERS ID: 1152288 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-01-07
Onset:2021-03-30
   Days after vaccination:82
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Odanestron, KCl, Levothyroxine, Duloxetine, Atorvastatin, amlodipine, aspirin, losartan, prednisone, azithromycin, omeprazole, metoprolol, finasteride, budesonide, ipratropium-albuterol
Current Illness: neuropathy, uti, anemia, BPH, depression, hypothyroid, COPD, HTN, CAD
Preexisting Conditions: neuropathy, uti, anemia, BPH, depression, hypothyroid, COPD, HTN, CAD
Allergies: lisinopril, penicillin, maxitrol, lemon
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 1152757 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-03-29
Onset:2021-03-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac death, Death, Malaise, Refusal of treatment by patient, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: 1. Colace 100 mg 3 capsules by mouth at bedtime. 2. Ropinirole 0.5 mg 1 tablet twice a day. 3. Percocet 325 every 6 hours as needed. 4. Nitro 0.4 under tongue as directed as needed. 5. Atorvastatin 40 mg daily. 6. Hydralazine 100 mg q. 8 ho
Current Illness: shortness of breath- 2/27/21 end-stage renal failure on dialysis- 2/27/21 to present
Preexisting Conditions: PMH: 1. Atherosclerotic heart disease with a NSTEMI and PCI in October of 2018. 2. Acute on chronic diastolic heart failure. 3. Coronary artery bypass graft in 2017 with a 3 vessel bypass. 4. Cardiac arrest with hypoxic encephalopathy following the coronary artery bypass graft procedure. 5. Chronic kidney disease. 6. Hypertension. 7. Dyslipidemia. 8. Obesity. 9. Insulin-dependent uncontrolled type 2 diabetes. 10. Peripheral vascular disease with a right below-the-knee amputation. 11. NSTEMI with cardiac stenting in October 2020. 12. Acute on chronic renal failure, October 2020. on dialysis (ordered 3 times per week, only goes twice per week) 13. Anemia secondary to CKD, October 2020. 14. Covid 19 infection in August of 2020.
Allergies: ALLERGIES: CAULIFLOWER WHICH CAUSES ANAPHYLACTIC SHOCK, CODEINE, LISINOPRIL, BENICAR, PENICILLIN, TRAMADOL, HE IS UNSURE OF WHAT THE ALLERGIC REACTION IS.
Diagnostic Lab Data: none
CDC Split Type:

Write-up: vaccine recieved 3/29/21, on 3/30/21 patient expired in his home. cause of death assumed to be cardiac related. Pt. was not feeling well after covid vaccination, therefore refused to go to dialysis (3/30/21). Collapsed in basement and was found by spouse 30 minutes later. Patient was DNR. spouse stated she feels death was not directly related to vaccine because he had several health conditions in which he has been noncompliant with and has not been following his medical providers treatment plans.


VAERS ID: 1154290 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: None that we are aware of
Current Illness: None that we are aware of
Preexisting Conditions: None that we are aware of
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient apparently woke up in the morning and told his wife that he was tired and went back to bed and did not wake up.


VAERS ID: 1157033 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: ESRD, Type II DM with diabetic CKD, Long term use of insulin, Iron deficiency anemia, unspecified, Anemia in CKD, unspecified protein-calorie malnutrition, Other disorders of phosphorus metabolism, Unspecified amyloidosis, Blindness both eyes, Hypertensive CKD with stage 5 CKD, renal osteodystrophy, secondary hyperparathyroidism of renal origin, dependence on renal dialysis, renal osteodystrophy
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per family patient reported c/o nausea and vomiting at home post treatment on 3/30/2021, he went to bed and was found unresponsive on 3/31, EMS was contacted and pronounced deceased at home on 3/31/2021. (exact time unknown).


VAERS ID: 1158952 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-18
Onset:2021-03-30
   Days after vaccination:40
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Occasional bronchial asthma and history of triple bypass surgery two years prior
Allergies: Sulfa
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death of patient reported to have happened on 3/30/2021


VAERS ID: 1163967 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021B21A / 2 RA / IM

Administered by: School       Purchased by: ?
Symptoms: Computerised tomogram abnormal, Death, Feeling abnormal, International normalised ratio increased, Thrombosis
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage laboratory terms (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Coumadin
Current Illness:
Preexisting Conditions: A fib
Allergies: None
Diagnostic Lab Data: CT scans in ER on 3/30+3/31
CDC Split Type:

Write-up: Felt crummy on day one and two better on day three and on day four developed four blood clots on Coumadin with an INR of 4.5 and died the next day on 3/31/2021.


VAERS ID: 1165154 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-12
Onset:2021-03-30
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Heart meds, blood thinners, and blood pressure meds.
Current Illness: Heart disease
Preexisting Conditions: Heart disease
Allergies: Penacilan
Diagnostic Lab Data: Yes
CDC Split Type:

Write-up: My husband died 18 days after the shot


VAERS ID: 1171278 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8730 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Reported on blood thinner
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: no known allergies
Diagnostic Lab Data: Daughter reported they had pacemaker removed at funeral home and took to cardiologist for evaluation. No report at this time.
CDC Split Type:

Write-up: No adverse events reported while client observed after vaccination. Received voice message on 4/6 from daughter that client had died several hours after receiving vaccine. Also reported he had underlying health issues so unsure of cause. I made telephone call to daughter on 4/6. Daughter was wanting report made and plans to do so with additional health information included. I informed daughter I would be making a report also.


VAERS ID: 1171887 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Complication associated with device, Death, Graft haemorrhage, Malaise
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Pravachol, Mag-Ox, Omeprazole, aspirin, Terazosin, Renvela, Catapres, Allopurinol, Labatolol, Amlodipine, Vit D3, Ventolin, Bumex
Current Illness:
Preexisting Conditions: ESRD, HTN, cerebal palsy, failed renal transplant, gout, hyperlipidemia, obesity, COPD, secondary hyperparathyroidism of renal origin, anema.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Notified by pt''s family member that pt stated at the dinner table he was not feeling well and went to lay down. Pt then later called out for his family member stating he was bleeding from his dialysis access in his leg. Pt''s family member called EMS, pt was transported to the hospital. Pt member stated the pt passed away that evening "because of all the blood he lost from his access." Pt''s nephrologist and NP were notified. Pt''s death per nephrologist was felt to be due to blood loss from his graft and not related to the vaccine.


VAERS ID: 1176064 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-26
Onset:2021-03-30
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving a COVID vaccine


VAERS ID: 1179434 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2021-03-01
Onset:2021-03-30
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aphasia, Blood glucose increased, Feeling abnormal, Influenza like illness, Mydriasis, Myocardial infarction, Nausea, Pain, Pallor
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin
Current Illness: None
Preexisting Conditions: Diabetes & muscular sclerosis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: She felt. Ad the evening of her 2nd vaccine. The morning after she felt worse. Nauseous, pale, achy. She said she had not ever felt that bad. I read possible side effects. It said flu like symptoms, so we thought it would pass. Then around 4 she called for me & when I got there she had an event that caused her to be unable to speak & her eyes widened & pupils were dilated. I called 911. They got here quick. She had at least three of those stiffening wide eyed events. The emt said they thought it was her blood sugar. When checked it was 350 even though she had taken her insulin that day. They said she had a massive heart attack on the way to the hospital.


VAERS ID: 1197395 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-03-30
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood culture positive, Chronic obstructive pulmonary disease, Death, Dyspnoea, Enterococcus test positive, Respiratory disorder, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient was COVID-19 negative on 3/26/2021 when he was admitted to facility.
CDC Split Type:

Write-up: Death Narrative: Patient received his first dose of the Moderna COVID-19 vaccination on 3/4/2021. He presented to facility 03/05/2021 for shortness of breath. He was originally treated for COPD exacerbation and COVID-19 was ruled out by negative testing. He was then found to have blood cultures positive for E. Faecalis. He was treated with broad spectrum antibiotics. His lack of improvement in respiratory status was the cause of discharge to hospice after which he died on 3/30/2021.


VAERS ID: 1200519 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER2613 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
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: 1201361 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-03-06
Onset:2021-03-30
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 28
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atenolol 100 MG, Atorvastatin 20 mg, Oxycodone Acetaminophen 10-325, Amlodipine Besylate 10 mg, Oxybuynin CL ER 10 mg, Prednisone 10 MG, Glipizide er 5 mg, Potassium CL ER 20 meq, Xeljanz XR 11 mg, Captopril 50 mg, Hydrochlorothiazide 25 mg
Current Illness: Cancer of the lung, trachea and bronchus that had metastasized to the liver and adrenal gland.
Preexisting Conditions: Cancer of the lung, trachea and bronchus that had metastasized to the liver and adrenal gland.
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient passed away between 3/30/21 and 4/1/21 at home.


VAERS ID: 1201981 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-24
Onset:2021-03-30
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: glucophage for diabetes
Current Illness: none
Preexisting Conditions: diabetes- non-insulin
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 7 days after the COVID vaccine, patient went into resp. arrest and died in the ER


VAERS ID: 1203939 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-17
Onset:2021-03-30
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP7534 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Encephalopathy, Pancytopenia, Pneumonia aspiration, Seizure, Septic shock
SMQs:, Agranulocytosis (narrow), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Systemic lupus erythematosus (broad), Toxic-septic shock conditions (narrow), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: NA Septic shock Aspiration pneumonia Acute encephalopathy Pancytopenia Seizure


VAERS ID: 1204502 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-03
Onset:2021-03-30
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
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 hospitalized and died within 60 days of receiving a COVID vaccine series


VAERS ID: 1204680 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / UNK - / SYR

Administered by: Pharmacy       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: 2021-03-30
   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: Aspirin, 81mg 1x day Carvedilol, 12.5 mg, 1 Tab twice daily Glimepride, 2mg, Take 1 tablet twice daily Losartan Potassium, 50 mg, Take 1 Tablet Daily Metformin HCI - 1000 mg, Take 1 Tablet twice daily Pioglitazone HCI, 30 mg, Take one table
Current Illness: Type II diabetes High Blood Pressure Interstitial Lung Disease
Preexisting Conditions: Type II diabetes Hypertension Interstitial Lung Disease
Allergies: Sensitive to Eggplant (food) No drug allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Suddent Death approximately 75 hours after second dose of Moderna Vaccine


VAERS ID: 1208477 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-03-19
Onset:2021-03-30
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure, Death, General physical health deterioration
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   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: Received Moderna vaccine on 2/29/21 and 3/19/2021. Health began declining 2 weeks later and died on 4/13/2021 (26 days post vaccination) with heart failure listed as cause of death.


VAERS ID: 1208709 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-03-01
Onset:2021-03-30
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8732 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain upper, Anal incontinence, Cardio-respiratory arrest, Death, Epistaxis, Extravasation blood, Nausea, Pain in extremity, Pallor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Prescription for high blood pressure Prescription for high cholesterol
Current Illness: No illness
Preexisting Conditions:
Allergies: No none allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: The information was presented by his granddaughter. He was scheduled to come in for his second vaccination with his granddaughter on 4/14/21, however, he passed away on 4/13/21. His granddaughter stated he experienced a severe nose bleed just under a week post vaccination (1st dose/Pfizer). The nose bleed lasted a few hours and had to be controlled by the Hospital. The incident reoccurred a week later and again, the bleeding had to be controlled by nasal clamp and lasted for a few hours. The patient began having pain in his stomach and feet, and stayed pale and nauseous. On 4/13/21 the patient was found in his bed saturated in blood and had soiled himself. His family called EMS and the patient went to Hospital. The patient coded and was not revived. The granddaughter stated that he had an enlarge prostate that was discovered during one of his hospital visits in the past 3 weeks.


VAERS ID: 1209415 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram head abnormal, Endotracheal intubation, Headache, Hypertension, Influenza like illness, Nausea, Pain, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Angioedema (broad), 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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   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: Risperidone, Seroquel, Lipitor, and Advair
Current Illness: None
Preexisting Conditions: COPD and High Cholesterol
Allergies: Penicillin and Gluten
Diagnostic Lab Data: Blood pressure: 262/130 on 4/1/2021. The blood pressure stayed high throughout hospital stay.
CDC Split Type:

Write-up: Patient experience flu like symptoms and body aches the same evening after receiving vaccine. On 4/1/21 the patient experienced nausea, high blood pressure, and a headache. Around 7:00 pm that night the patient threw up and became unresponsive. The patient was then transported to the hospital by ambulance. A CT scan showed a brain bleed and the patient was intubated and transferred to another hospital.


VAERS ID: 1210581 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-24
Onset:2021-03-30
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8732 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Death, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   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: Hospitalization due to previous respiratory arrest 16 days after first Pfizer Covid vaccine. MDs believed to be unrelated and encouraged pt to rcv second dose.
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: Daughter in law has access to lab information and can report.
CDC Split Type:

Write-up: Patient''s daughter in law called to report the adverse event and will be submitting a VAERS as well. Pt rcvd first dose of vaccine 03/03 and 16 days later on 03/19 he was hospitalized for respiratory unrest, cause unknown. It was not suspected to be caused by the vaccine at that time. Doctors encouraged him to rcv the second dose and pharmacy staff was informed pt had been given the go ahead to do so. Pt marked that he was not currently ill on his informed consent form and that he had not had a previous reaction to the vaccine. 5 days after rcving his second dose (03/30) he arrested again resulting in hospitalization later death on 4/4.


VAERS ID: 1212373 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-24
Onset:2021-03-30
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Back pain, Constipation, Death, Dyspnoea, Headache, Procedural pain
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Lisinopril-HCTZ, Vacepa, Metoprolol, Replax, Calcium, Multi-vitamin, Diclofenac, Omperazole
Current Illness: Underwent L4-L5 posterior lumbar laminectomy and fusion with instrumentation 3/24/2021
Preexisting Conditions: Hypertension, Migraines, GERD, spinal stenosis, chronic back pain
Allergies: None documented
Diagnostic Lab Data: None available
CDC Split Type:

Write-up: The patient had an uneventful post-operative course and was discharged on post-op day 2. By report, on post op day 4-5, the patient began complaining of headache, back pain and abdominal pain. Continued home meds for post-op pain and constipation. On POD 8/9, the patient notified her daughter that she woke up short of breath. She was transferred by EMS to Hospital where she reportedly expired (this event was reported by the patient''s daughter to doctor''s office, the spine surgeon who managed her while inpatient at Hospital


VAERS ID: 1212788 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-23
Onset:2021-03-30
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / N/A LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown to pharmacy
Allergies: no allergies reported on vaccine consent form
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife notified our corporate office on 4/15/21 that her husband received a J&J COVID vaccine from our pharmacy on 3/23/2021 and that he passed away one week later, 3/30/2021, in their yard after having a heart attack. Phone number provided is the wife''s.


VAERS ID: 1236415 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-25
Onset:2021-03-30
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received Moderna covid vaccine #1 on 3/25/21. No notes entered after this time and date of death is recorded as 3/30/21. No scanned records. No autopsy results available. 5 days from date of vaccine to date of death.


VAERS ID: 1241400 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-01
Onset:2021-03-30
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cerebral circulatory failure, Death, Fall, Head injury
SMQs:, Accidents and injuries (narrow), Central nervous system vascular disorders, not specified as haemorrhagic or ischaemic (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was a resident at an assisted living facility and by 3/11/21 he had several falls within the last week, one of which he hit his head and need to be evaluated by the ER due to him being on warfarin. Patient had dementia and psychosis and told wife he was falling intentionally. He deceased at the rehab facility on 3/30/21 after requiring hospitalization 4 times over the last for not getting blood flow to his brain per wife.


VAERS ID: 1237530 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: BLOOD THINNING, THYROID, HYPERTENSION
Current Illness: NONE
Preexisting Conditions:
Allergies: PENICILLIN AND GARLIC
Diagnostic Lab Data: At age 91 we did not do an autopsy
CDC Split Type:

Write-up: Mom was feeling fine the day of the vaccine. Last spoke with her at 6:30 PM and she said she wasn''t feeling anything but would go to bed early. I said OK I will check on you in the morning. She never woke up!


VAERS ID: 1238418 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Ammonia normal, Blood chloride increased, Blood creatinine normal, Blood glucose increased, Blood sodium increased, Blood urea increased, Carotid artery stenosis, Cerebrovascular accident, Haematocrit decreased, Haemoglobin increased, Pulmonary mass, Red blood cell count decreased, Vertebral artery occlusion
SMQs:, Acute renal failure (broad), Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Depakote, Humalog, Knatus, MVI with minerals, Plavix, Synthroid, Zyprexa, Lactulose, Metoprolol Tartrate,
Current Illness: 3/8- Zyprexa dose was increased due to behaviors. 3/16- Resident noted to have increased fatigue, ? related to medication adjustment. 3/22 Unsteady on feet with walker. 3/23- Unwitnessed fall, sent to ER CT scan of neck and head is negative. X-ray of pelvic region is negative. 3/24 Zyprexa dose adjusted to be given at HS after fall x2. 3/26- Received 1st dose of Pfizer. Personal Hx of Covid-19 infection, received monoclonial antibodies on 12/20/2020.
Preexisting Conditions: Gait and mobility abnormality, Dysphagia, Dementia with behaviors, Osteoarthritis, MDD, Paranoid personality, AV block-first degree, Type 2 DM, Hyperlipidemia, HTN, Atherosclerotic heart disease of native coronary artery, Abnormal liver function studies,
Allergies: Codeine, Gadolinium Derivatives, Contrast Dye.
Diagnostic Lab Data: 3/30- Resident was sent to ER was found to have acute CVA, R vertebral occlusion, carotid stenosis, 17mm lung mass suspicious for malignancy. 04/05- BUN- 29, CREA- 0.82, Chloride-113, RBC- 3.81, H/H- 11.3/34.7. 04/07- Positive for C.diff. 4/8- H/H- 4.37/12.9. BUN- 21, CREA-= 0.78, Chloride- 115. 04/13- Glucose--296, Sodium- 148, Chloride- 117, WBC- 13.80, RBC- 4.59, H/H- 13.2/43.2, Glucose- 252, BUN- 32, CREA-1.14 , Sodium- 150, Chloride- 118, Ammonia level- 15.
CDC Split Type:

Write-up: 3/30- Resident was sent to ER was found to have acute CVA, R vertebral occlusion, carotid stenosis, 17mm lung mass suspicious for malignancy, family opted for palliative and or Hospice. 4/03-re-admitted to the facility. 4/14 Admitted to Hopsice. Resident deceased on 4/16.


VAERS ID: 1245000 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-03-10
Onset:2021-03-30
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram thorax abnormal, Pulmonary embolism, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Unknown
Current Illness: None
Preexisting Conditions: High blood pressure
Allergies: None
Diagnostic Lab Data: CT scan
CDC Split Type:

Write-up: Blood clots in the lungs, pulmonary embolism


VAERS ID: 1245370 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Fatigue, Influenza like illness, Vaccination site pain
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   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: OXYCODONE; AMBIEN CR; BAYER ASPIRIN; CARDIZEM CD; COMPAZINE [PROCHLORPERAZINE EDISYLATE]; IRBESARTAN; IMITREX [SUMATRIPTAN]; LEFLUNOMIDE; NEURONTIN; PILOCARPINE; PREVACID; RINVOQ; SINGULAIR; TIZANIDINE; VALIUM; ZOFRAN [ONDANSETRON]; CBD OIL
Current Illness: Degenerative bone disease; Dermatomyositis; Immune disorder (NOS); Muscular dystrophy; Osteoarthritis; Osteoporosis; Polymyositis; Raynaud''s phenomenon; Rheumatoid arthritis
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: very tired and sleep 18 hours; passed away; severe flu-like symptoms; chest pain; Soreness at injection site; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (passed away) in a 54-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 020B21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Dermatomyositis, Polymyositis, Osteoarthritis, Degenerative bone disease, Osteoporosis, Muscular dystrophy, Rheumatoid arthritis, Immune disorder (NOS) and Raynaud''s phenomenon. Concomitant products included MONTELUKAST SODIUM (SINGULAIR) for Asthma, PILOCARPINE for Dry mouth, IRBESARTAN for Hypertension, DILTIAZEM HYDROCHLORIDE (CARDIZEM CD) for Hypertension and Chest pain, SUMATRIPTAN (IMITREX [SUMATRIPTAN]) for Migraine, TIZANIDINE for Muscle spasms, PROCHLORPERAZINE EDISYLATE (COMPAZINE [PROCHLORPERAZINE EDISYLATE]) and ONDANSETRON (ZOFRAN [ONDANSETRON]) for Nausea, GABAPENTIN (NEURONTIN) for Nerve pain, OXYCODONE for Pain, LEFLUNOMIDE and UPADACITINIB (RINVOQ) for Rheumatoid arthritis, ZOLPIDEM TARTRATE (AMBIEN CR), ACETYLSALICYLIC ACID (BAYER ASPIRIN), LANSOPRAZOLE (PREVACID), DIAZEPAM (VALIUM), CANNABIDIOL (CBD OIL) and IRON (IRON COMPLEX [IRON]) for an unknown indication. On 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 30-Mar-2021, the patient experienced VACCINATION SITE PAIN (Soreness at injection site). On 31-Mar-2021, the patient experienced INFLUENZA LIKE ILLNESS (severe flu-like symptoms) and CHEST PAIN (chest pain). On an unknown date, the patient experienced FATIGUE (very tired and sleep 18 hours). On 02-Apr-2021, INFLUENZA LIKE ILLNESS (severe flu-like symptoms), CHEST PAIN (chest pain), FATIGUE (very tired and sleep 18 hours) and VACCINATION SITE PAIN (Soreness at injection site) outcome was unknown. The patient died on 02-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. On 02-APR-2021 at 1: 30 AM mother found her daughter lying on the floor unresponsive. Paramedics and police came to the house. Paramedics tried to revive her and she was pronounced dead at the scene. This is a 54 year-old, female patient who received mRNA-1273 Vaccine) (batch no. 020B21A) and died 3 days after receiving first dose of vaccine and experiencing Influenza like symptoms. Medical hx of several auto immune disorders were provided. Conmeds include Hypertensive and Chest pain meds. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected.; Sender''s Comments: This is a 54 year-old, female patient who received mRNA-1273 Vaccine) (batch no. 020B21A) and died 3 days after receiving first dose of vaccine and experiencing Influenza like symptoms. Medical hx of several auto immune disorders were provided. Conmeds include Hypertensive and Chest pain meds. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1146768 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-26
Onset:2021-03-29
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Diabetes, COPD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1147392 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-24
Onset:2021-03-29
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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 TAB 10MG TAKE ONE-HALF TABLET BY MOUTH DAILY FOR BLOOD PRESSURE AND HEART LISINOPRIL*HIGH ALERT* TAB 20MG TAKE ONE-HALF TABLET BY MOUTH DAILY FOR BLOOD PRESSURE FOLIC ACID TAB 1M
Current Illness: Unknown --last visit with Dr was 2/3/2021.
Preexisting Conditions: Type 2 diabetes mellitus well controlled (SCT 444110003) Primary ICD-10-CM: E11.9 [Type 2 diabetes mellitus without complications] History of placement of stent for coronary artery disease (SCT 428375006) Primary ICD-10-CM: R69. [Illness, unspecified] Bladder cancer (SCT 399326009) SNOMED-CT: Malignant tumor of urinary bladder Primary ICD-10-CM: D09.0 [Carcinoma in situ of bladder] Treated and resolved in 2012. Benign essential hypertension (SCT 1201005) Primary ICD-10-CM: I10. [Essential (primary) hypertension] Solitary nodule of lung (SCT 427359005) Primary ICD-10-CM: R91.1 [Solitary pulmonary nodule] Chronic obstructive lung disease (SCT 13645005) Primary ICD-10-CM: J44.9 [Chronic obstructive pulmonary disease, unspecified] Cataract (SCT 193570009) Primary ICD-10-CM: H25.10 [Age-related nuclear cataract, unspecified eye] Hyperlipidemia Gouty arthritis
Allergies: Soft drinks --rash
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Death--Patient woke up in morning and c/o not feeling well. Died in route to hospital.


VAERS ID: 1147433 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-03-16
Onset:2021-03-29
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH #EP7534 / 1 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: breast cancer 20 years ago, neuropathy, bilateral knee replacement, DVT 15 years ago
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Decedent received first Covid-19 vaccination on 03/16/2021, has not been feeling well the past week. This past week the decedent stated she had been more tired and was experiencing shortness of breath.


VAERS ID: 1147618 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-22
Onset:2021-03-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest
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: 2021-03-29
   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: metformin, coreg, proton pump inhibitor
Current Illness:
Preexisting Conditions: diabetes, hypertension, alcohol use, anemia
Allergies: sulfa
Diagnostic Lab Data: none
CDC Split Type:

Write-up: cardiac arrest


VAERS ID: 1148858 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-26
Onset:2021-03-29
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8727 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: UNKNOWN SINCE PT''LAST FILLED PRESCRIPTION IN THE PHARMACY WAS ON 8/31/2020 FOR NOVOLOG, CARAFATE, COREG, PEPCID AND LASIX
Current Illness: PT IS ON DIALYSIS THREE TIMES WEEKLY
Preexisting Conditions:
Allergies: NO NKOWN DRUG ALLERGY
Diagnostic Lab Data:
CDC Split Type:

Write-up: UNKNOWN. PT''S WIFE CALLED US TODAY 3/30/2021 TO INFORM US THAT PATIENT PASSED AWAY ON 3/29/2021 DUE TO MASSIVE HEART ATTACKED


VAERS ID: 1154856 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-03-29
Onset:2021-03-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 1 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Death, Hypersensitivity
SMQs:, Angioedema (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: No
Current Illness: No
Preexisting Conditions: No
Allergies: No
Diagnostic Lab Data: Currently awaiting coronary results they took tissue sample
CDC Split Type:

Write-up: My sister died due to allergic reaction 45min after taking the Moderna Vaccine


VAERS ID: 1155594 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-19
Onset:2021-03-29
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8727 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Patient death within 60 days of receiving a COVID vaccine


VAERS ID: 1155752 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-10
Onset:2021-03-29
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Patient death within 60 days of receiving a COVID vaccine


VAERS ID: 1156328 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-03-03
Onset:2021-03-29
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: UnKnown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 03/29/2021


VAERS ID: 1159101 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-25
Onset:2021-03-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Decreased appetite, Fatigue, Mobility decreased, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   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: Baby aspirin 81 mg
Current Illness: Ill feeling starting 3 days after 1st Covid Vaccine lasting 3 plus days
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Patient was resting and recouping from symptoms at home and was taking hydration and nutrition drinks along with smaller meals due to fact he was feeling ill with no appetite.
CDC Split Type:

Write-up: My Father was ill for approx 3-4 days after first vaccine with fatigue and some minor chest pressure, this start approx 3 days after injection and had made a complete recover, he then recieved his 2nd vaccine shot and again 3-4 days later he again stated began having severe fatigue and mobility issues, ( he stated his legs felt like jello ) , no chest pains and no breathing issues were associated. 3 days later he was still feeling the same with symptoms and on the 4 day he was found deceased in his home.


VAERS ID: 1172711 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-27
Onset:2021-03-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram head abnormal, Death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Benefiber, Duloxetine, Ezetimibe, Famotidine, finasteride, pantoprazole, Tamsulosin, telmisartan-HCT Trulance, Vitamin D3
Current Illness:
Preexisting Conditions: HTN, BPH, GERD, Depression
Allergies: Sulfa
Diagnostic Lab Data: CT Brain; March 29, 2021
CDC Split Type:

Write-up: @nd dose Pfizer on March 27 without immediate problems. Had sudden collapse on March 29, found to have large intracerebral hemorrhage; at local hospital after discussion placed on comfort measures only; died 04/02/2021


VAERS ID: 1179974 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-18
Onset:2021-03-29
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, Respiratory failure, 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), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 8
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: unknown
Current Illness: pt diagnosed with COVID on 3-29-21, was hospitalized, developed pneumonia and respiratory failure and expired on 4-6-21
Preexisting Conditions: HTN/GERD
Allergies: nkda
Diagnostic Lab Data: COVID + PCR on 3-29-21
CDC Split Type:

Write-up: pt was diagnosed with covid on 3-29-21 , hospitalized for pneumonia and respiratory failure and expired on 4-6-21 at Hospital


VAERS ID: 1185996 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-03-27
Onset:2021-03-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Diabetes, ulcerative colitis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My father complained of chest pains and then died two days after receiving the vaccine.


VAERS ID: 1188519 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-03-29
Onset:2021-03-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER2613 / 2 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Pulse absent, Respiratory arrest, Resuscitation, Tremor, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (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 (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: - phosphate binders - metoprol - nephro Vit - simvastatin - amlodipine besylate 5mg
Current Illness: - chronic kidney disease - On dialysis
Preexisting Conditions: - chronic kidney disease. On dialysis - heart EFR low during covid admission in Oct. 2020 - diagnosed with covid in October 2020 and was hospitalized for 13 days.
Allergies: bananas
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: On 3/29/21 at 11:00pm my dad began having chills and uncontrollable shaking. My mother contacted Pfizer who instructed us to alternate Tylenol and Motrin. Tylenol given and Motrin given 4 hours later as instructed by Pfizer. On 3/30/21 around 11:10am my dad was found unresponsive, not breathing and did not have a pulse. My mother immediately called 911 and my aunt began CPR. When EMS arrived he was found to be in cardiac arrest and after 25 min of efforts by EMS my father passed away less than 24 hours after receiving his 2nd covid vaccine.


VAERS ID: 1207286 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-17
Onset:2021-03-29
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9267 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Death


VAERS ID: 1213131 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-11
Onset:2021-03-29
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / UNK RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Fall, Hip fracture, Spinal fracture, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 0
Permanent Disability? No
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: Diabetic Medications (Pills)
Current Illness: broke 3 back bones and hip chip due to fall 3/22/2021 a store parking lot
Preexisting Conditions: Diabetic
Allergies: none
Diagnostic Lab Data: AUTOPSY PERFORMED AND CONFIRMED
CDC Split Type:

Write-up: PATIENT DIED FROM BLOOD CLOT 3/29/2021 - AUTOPSY PERFORMED AND CONFIRMED


VAERS ID: 1236406 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-03-29
   Days after vaccination:62
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Incomplete course of vaccination
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: pt had first vaccine on 1/26; caregiver declined second dose due to concerns of side effects; pt died 3/29/21 (not from COVID)


VAERS ID: 1221916 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-02-27
Onset:2021-03-29
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001821A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Brain death, Cerebral thrombosis, Loss of consciousness, X-ray
SMQs:, Torsade de pointes/QT prolongation (broad), 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), 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: 2021-04-08
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (no medical history reported)
Allergies:
Diagnostic Lab Data: Test Date: 20210330; Test Name: x-ray; Test Result: Positive ; Result Unstructured Data: x-rays revealed blood clot in his brain
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: blood clot in his brain; Patient collapsed on the floor at night 2 days after receiving 2nd dose; brain was dead; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of BRAIN DEATH (brain was dead), CEREBRAL THROMBOSIS (blood clot in his brain) and LOSS OF CONSCIOUSNESS (Patient collapsed on the floor at night 2 days after receiving 2nd dose) in an 83-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 0021B21A and 001821A) for COVID-19 vaccination. The patient''s past medical history included No adverse event (no medical history reported). On 27-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 27-Mar-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 29-Mar-2021, the patient experienced LOSS OF CONSCIOUSNESS (Patient collapsed on the floor at night 2 days after receiving 2nd dose) (seriousness criterion hospitalization prolonged). On 30-Mar-2021, the patient experienced CEREBRAL THROMBOSIS (blood clot in his brain) (seriousness criteria death and hospitalization prolonged). The patient died on 08-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, LOSS OF CONSCIOUSNESS (Patient collapsed on the floor at night 2 days after receiving 2nd dose) outcome was unknown. Not Provided DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 30-Mar-2021, X-ray: blood clot (Positive) x-rays revealed blood clot in his brain. No concomitant medications were reported. After the 2nd dose, On 29Mar2021, at night, he collapsed on the floor and was taken at the hospital on same night by ambulance. So he was hospitalized on 30Mar2021 and upon doing tests and x-rays, they found blood clot in his brain. He stayed in hospital through out and transferred to hospice center on 06Apr2021 where he passed away on 08Apr2021. His brain was dead and never recovered from the clot. Unknown treatment medications were given at the hospital. Very limited information regarding these events have been provided at this time. No further information is expected.; Sender''s Comments: Very limited information regarding these events have been provided at this time. No further information is expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1230283 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-29
Onset:2021-03-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute cardiac event, Death, Resuscitation
SMQs:, Myocardial infarction (narrow), Other ischaemic heart disease (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: heart disease per EMS report
Allergies: none reported
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Reported to the vaccination clinic by county EMS: Pt expired at his home following a call to 911 for a cardiac event for which resuscitation efforts were unsuccessful. This occured on the same day as his last dose of the Moderna vaccine.


VAERS ID: 1232138 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-03-17
Onset:2021-03-29
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026AZ1A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Aspiration, Cough, Myocardial infarction, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   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: Mirtazapine, Gabapentin, Vitamin D3, Acetaminophen 325 mg
Current Illness: None reported
Preexisting Conditions: Dementia, Severe Dysphagia type 3, High Blood Pressure, Cardiac. Stagnant
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-114-21

Write-up: Resident began coughing then complained of abdominal pain and was taken to the Hospital. He began to vomit and breathed in. Had a heart attack


VAERS ID: 1233617 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-24
Onset:2021-03-29
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 2 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood creatinine increased, Blood glucose normal, Cardiac arrest, Cardiac disorder, Death, Echocardiogram abnormal, Endotracheal intubation, Feeling abnormal, Haemoglobin decreased, Heart injury, Illness, Liver function test increased, Malaise, Mechanical ventilation, Multiple organ dysfunction syndrome, Renal impairment, Resuscitation, SARS-CoV-2 test negative, Sedation, Troponin increased, Unresponsive to stimuli, Vomiting, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), 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 (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: insulin
Current Illness:
Preexisting Conditions: type 2 diabetes
Allergies:
Diagnostic Lab Data: creatine, gsr...went to quarterly dr. appointments to address diabetes, last one was in january...was taking care of self..
CDC Split Type:

Write-up: 5:30 pm 3/29/21 received phone call from aunt that ems had taken dad to hospital because he was feeling unwell. he vomited prior before and just didn''t feel right. ems showed up and observed him, glucose was 139..not out of range...vitals stable..2nd moderna vaccine 5 days prior...ems said that is was probably side effects...asked if he really wanted to go in...said yes, took him to hospital...5:45 daughter called hospital to get status check....she is poa for medical...er doc said he was intubated and on vent.....er doc said he was very sick...6:50 pm daughter got to er and room he was on vent and knocked out...he had antibiotics, sleeping meds..meds to rise bp in iv.....er doc came in daughter asked why he was on vent...asked about o2 doc said he was fine just unresponsive...labs were being done at time...had him on dextrose, propofol, dexmedtominine,..asked to have him transferred to own hospital..8:10 dr. comes in with lab results...kidneys and livers were showing multi organ failure...triponin was high as well..red flags were: creatine 9.93, gsr-5, hemoglobin-7, liver lft-500, triponin 14, covid test was negative, white count was in range, daughter mentioned vaccine again and doc said nothing nor did she mention heart being in trouble, no answers regarding what the cause of this was...for the record he only had kidney issues due to type 2 diabetes, was not at dialysis level...9:30 ems shows up to take dad to another hospital were not ready from him yet...9:41 dad heart started to drop on monitor withing 15 secodes iit flatlined in front of daughter......med staff did cpr...brought in epi pens and manual cpr for heart...a little after 10 heart was started it ran for 4 minutes then crashed again..10:05 continued cpr until 10:28, dr showed that walls i heart not squeezing very damaged, brought in echo during process, 10:28 time of death


VAERS ID: 1240207 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-18
Onset:2021-03-29
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Death, Fatigue, Head discomfort, Paranasal sinus discomfort, 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: 2021-03-30
   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: none
Current Illness: None
Preexisting Conditions: None
Allergies: None known
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Symptoms of tiredness and head sinus pressure came on throughout the day monday 3-29-21. Symptoms were unchanged tues morning 3-30-21. She died Tuesday 3-30-21 between 10:34 am and 12:00 pm. She was found unresponsive at 12:07 pm when husband returned home for lunch. Autopsy results still pending.


VAERS ID: 1248554 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-15
Onset:2021-03-29
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiovascular disorder, Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: AUTOPSY REPORT SHOWS HYPERTENSION AND CARDIOVASCULAR DISEASE
CDC Split Type:

Write-up: PATIENT RECEIVED THE VACCINE ON 3/15, HE PASSED AWAY ON 3/29


VAERS ID: 1261526 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-03-24
Onset:2021-03-29
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Blood creatine, Cardiac failure, Glomerular filtration rate, Haemoglobin, Hypotension, Liver function test, Renal failure, SARS-CoV-2 test, Troponin, Troponin increased, Type 2 diabetes mellitus, White blood cell count
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (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), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Multi organ failure (Kidneys and liver are VERY messed up showing multi-organ failure.); Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: creatine; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: GFR; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: GFR; Test Result: Inconclusive ; Result Unstructured Data: 5.0; Test Name: hemoglobin; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: Liver lft; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: covid test; Test Result: Negative ; Result Unstructured Data: Negative; Test Name: Covid test; Test Result: Negative ; Result Unstructured Data: Negative; Test Name: TROPONIN; Test Result: Inconclusive ; Result Unstructured Data: 14.0; Test Name: triponin; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: wbc; Result Unstructured Data: normal (in range)
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Type 2 Diabetes; Hypotension; heart started to drop; Renal failure; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 20-Apr-2021 and was forwarded to Moderna on 20-Apr-2021. This spontaneous case was reported by a patient family member or friend (subsequently medically confirmed) and describes the occurrence of CARDIAC FAILURE (heart started to drop), RENAL FAILURE (Renal failure), TYPE 2 DIABETES MELLITUS (Type 2 Diabetes) and HYPOTENSION (Hypotension) in a 69-year-old patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Multi organ failure (Kidneys and liver are VERY messed up showing multi-organ failure.) and Type 2 diabetes mellitus. On 24-Mar-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 29-Mar-2021, the patient experienced CARDIAC FAILURE (heart started to drop) (seriousness criteria death and medically significant) and RENAL FAILURE (Renal failure) (seriousness criteria death and medically significant). On an unknown date, the patient experienced TYPE 2 DIABETES MELLITUS (Type 2 Diabetes) (seriousness criterion death) and HYPOTENSION (Hypotension) (seriousness criterion death). The patient died on 29-Mar-2021. The reported cause of death was Renal failure, type 2 diabetes, Hypotension and heart started to drop. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood creatine: 9.93 (Inconclusive) Inconclusive. On an unknown date, Glomerular filtration rate: 5 (Inconclusive) Inconclusive and 5.0 (Inconclusive) 5.0. On an unknown date, Haemoglobin: 7 (Inconclusive) Inconclusive. On an unknown date, Liver function test: 500 (Inconclusive) Inconclusive. On an unknown date, SARS-CoV-2 test: negative (Negative) Negative and negative (Negative) Negative. On an unknown date, Troponin: 14 (Inconclusive) 14.0. On an unknown date, Troponin increased: 500 (Inconclusive) Inconclusive. On an unknown date, White blood cell count: normal (normal) normal (in range). The action taken with mRNA-1273 in response to the event was not applicable. He was feeling unwell. He had vomited prior and felt sick. His blood sugar was 136 or 139, nothing bad. Treatment details included antibiotics going into him, sleeping meds, meds to rise his blood pressure,Dextrose, Propofol, Dexmedtominine. Company comment: This is a 69-year-old, patient of unknown gender who received mRNA-1273 Vaccine who experienced cardiac failure and died, 6 days after receiving second dose of vaccine. Medical history includes Type 2 diabetes mellitus and Multi organ failure. No conmeds were provided. Very limited information has been reported at this time. No further information is expected.; Sender''s Comments: This is a 69-year-old, patient of unknown gender who received mRNA-1273 Vaccine who experienced cardiac failure and died, 6 days after receiving second dose of vaccine. Medical history includes Type 2 diabetes mellitus and Multi organ failure. No conmeds were provided. Very limited information has been reported at this time. No further information is expected.; Reported Cause(s) of Death: renal failure; type 2 diabetes; hypotension; heart started to drop


VAERS ID: 1271305 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-03-29
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Death within 60 days of vaccine


VAERS ID: 1293211 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-29
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-05-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Hypotension, Hypoxia, Pneumonia, Sepsis
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 37
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: J18.9 - Pneumonia I95.9 - Hypotension R09.02 - Hypoxia I48.91 - Atrial fibrillation with rapid ventricular response (CMS/HCC) A41.9 - Sepsis, unspecified organism


VAERS ID: 1293462 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-29
Onset:2021-03-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 LA / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-05-04
   Days after onset: 36
Permanent Disability? Yes
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: This 64 year old male received the Covid shot on 3/29/21 and went to the ED on 3/29/21 and was admitted for left-sided nontraumatic intracerebral hemorrhage and died on 5/4/21. Please refer to the other details submitted within this report and contact the person who submitted this report via email for additional follow up details and investigation.


VAERS ID: 1144220 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-12
Onset:2021-03-28
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Bacteraemia, Blood culture positive, Cardiac telemetry, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram abnormal, Computerised tomogram head, Computerised tomogram thorax, Death, Endotracheal intubation, Full blood count, Metabolic function test, Pulseless electrical activity, Respiratory distress, Respiratory failure, Streptococcal sepsis, Streptococcus test positive, Ultrasound Doppler, Ultrasound abdomen
SMQs:, Anaphylactic reaction (broad), Angioedema (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 (narrow), Guillain-Barre syndrome (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 0
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: Loratadine Coreg Protonix Flonase Synthroid Alprazolam
Current Illness:
Preexisting Conditions: Atrial fibrillation Hypertension Hypothyroidism Anxiety Allergic rhinitis
Allergies: Losartan Penicillin
Diagnostic Lab Data: Blood cultures Ct Brain 3/16 Ct thorax 3/16 Ct abdomen 3/16 Chest X-ray 3/16, 3/17, 3/18, 3/20, 3/22, 3/24, 3/25, 3/26, 3/27 Us LE venous duplex 3/16 US gallbladder 3/16 CBC, CMP daily from 3/16-3-27 Cardiac telemetry
CDC Split Type:

Write-up: Bacteremia - strep epidermidis, developed respiratory distress required intubation for hypercapnic respiratory failure. Developed PEA on 3/28 died.


VAERS ID: 1145488 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-25
Onset:2021-03-28
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Unknown
Current Illness:
Preexisting Conditions: congestive heart failure, kidney failure, diabetes
Allergies: none
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 1145887 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-23
Onset:2021-03-28
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram head abnormal, Death, Endotracheal intubation, Haemorrhage intracranial, Headache, Intensive care, Malaise, Platelet count decreased
SMQs:, Angioedema (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 1
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: Aspirin 81 mg daily, Metformin, Claritin
Current Illness: Breast cancer, DCIS, completed radiation therapy March 9, 2021. No chemotherapy
Preexisting Conditions: DCIS Breast cancer diagnosed December 2020
Allergies: Sulfa
Diagnostic Lab Data: March 29, 2021 CT Brain: large intracranial hemorrahge platelet count 4,000
CDC Split Type:

Write-up: She received the vaccine on March 23. On March 28 she felt unwell and early on March 29, 2021 developed severe headache and came to the Medical Center ER. She had a large intracranial hemorrhage. Platelet count was 4,000. She had a normal platelet count in December 2020. She had not received chemotherapy for her breast cancer, only radiation. The hemorrhage rapidly expanded. She was intubated and admitted to the ICU under my care. Her husband opted for palliative extubation and she died soon after.


VAERS ID: 1148250 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-19
Onset:2021-03-28
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death, Feeling cold, Pulse absent, Resuscitation
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: 2021-03-28
   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: No current outpatient medications on file.
Current Illness:
Preexisting Conditions:
Allergies: nka
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 3/28/21 ER HPI 66 y.o. male who presents with cardiac arrest. Wife said patient went to load machines in the truck between 6:30 p.m. to 7:00 p.m. and about 745 p.m. when she did not see him, she went searching for him and found him about 8:15 p.m. without pulseless and cold. EMS was called and they got there about 8:23 p.m. and started CPR and brought the patient to the emergency room at at 9:05 p.m. and he was certified dead at 2110 p.m.


VAERS ID: 1149813 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-26
Onset:2021-03-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: COPD, HEART DISEASE
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: PT RECEIVED MODERNA #1 ON 3/26 AND PASSED AWAY ON 3/28 AT HOME.


VAERS ID: 1156029 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-03-28
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving the COVID vaccine series


VAERS ID: 1157534 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-03-28
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

Administered by: Other       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: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type: USJNJFOC20210356482

Write-up: DEATH; This spontaneous report received from a consumer via a company representative concerned a female of unspecified age. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown, expiry date: Unknown) dose, start therapy date were not reported for prophylactic vaccination. The Company is unable to perform follow-up to request batch/lot numbers. No concomitant medications were reported. On 28-MAR-2021, the patient received vaccine shot and she died on the same day. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. This report was serious (Death and Other Medically Important Condition).; Sender''s Comments: 20210356482 - Covid-19 Vaccine Ad26.Cov2.S - Death. This event is considered Unassessable. The event has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event.


VAERS ID: 1157805 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-03-25
Onset:2021-03-28
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had the 2nd Vaccine on 3-25-2021 and Passed away on 3-28-2021. our tech found out. No clue if it is related to the vaccine or not.


VAERS ID: 1158955 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-26
Onset:2021-03-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Glucontrol 5mg Lopressor 50mg Motrel
Current Illness: Diabetes, hypertension, chronic renal disease
Preexisting Conditions: Diabetes, hypertension, chronic renal disease
Allergies: Penicillin Bactrim
Diagnostic Lab Data:
CDC Split Type:

Write-up: Deceased


VAERS ID: 1164535 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-28
Onset:2021-03-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8732 / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 6
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: Coumadin, metoprolol, diltiazem, digoxin
Current Illness: none known
Preexisting Conditions: Congestive Heart Failure, Hypertension, constipation, Atrial Fibrillation and an essential tremor
Allergies: none known
Diagnostic Lab Data: None available to the Vaccination Center.
CDC Split Type:

Write-up: The patient presented for his second Pfizer Covid-19 vaccination on 28MAR2021. On his way into the Vaccination Center, he was blown over by high winds sustaining a blow to his right forehead with small abrasion and a 3x4cm subcutaneous hematoma. He was assisted to a wheel chair and brought into the EMT booth for further assessment. He was awake and alert and oriented during his time with us. He never lost consciousness . He vigorously requested to receive the Covid-19 vaccination which we complied with. Due to the mechanism of injury and use of an anticoagulant, he was subsequently transfered to Hospital for further assessment and care. We heard on 4/3/21 of his death.


VAERS ID: 1169170 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-03-27
Onset:2021-03-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER2613 / 1 UN / SYR

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Back pain, Blood pressure increased, Breast pain, Chest pain, Decreased appetite, Hypertonic bladder, Liver function test increased, Nausea, Vomiting
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Cardiomyopathy (broad), Lipodystrophy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan, Citalopram, Levothyroxine, multivitamin
Current Illness: None.
Preexisting Conditions: Shingles.
Allergies: Lisinopril
Diagnostic Lab Data: 3/30/2021 AM = ER = Epigastric abdominal pain, Elevated BP, vomiting, nausea, LFT elevation, more...
CDC Split Type:

Write-up: 3/30/21 AM = (Patient''s notes) "Chest/breast PAIN throughout night and (previous) day. Pain continuously in back last two (2) days. Nauseated, weak bladder every hour or so. No appetite. 1st Covid shot 3-27.


VAERS ID: 1180189 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-23
Onset:2021-03-28
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: A-Fib, hyperlipidemia, hypertension, pacemaker, kidney stones, Stroke, wound cellulitis, CAD, COPD/asthma, BPH, Gerd
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalization within 30 days of vaccination. Death within 60 days of vaccination


VAERS ID: 1188345 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-12
Onset:2021-03-28
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient''s wife came into our clinic today for her second Moderna dose and reported to us that her husband (the patient) had died on March 28, 2021 of a NON-COVID cause. She did not specify how he died. She gave us his vaccine card in case we needed to do anything with it. This RN is reporting as the client died roughly two weeks after administration of the 1st dose and it was reported directly to the facility, although the death is not COVID related according to the patient''s wife.


VAERS ID: 1191920 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-03-28
Onset:2021-03-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8730 / 1 RA / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Inappropriate schedule of product administration, Overdose
SMQs:, Drug abuse and dependence (broad), Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: TYLENOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Abdominal aortic aneurysm; Aneurysm cerebral; Arthritis; Coronary artery disease; Hypertension; Parkinson''s disease
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021359777

Write-up: Sudden Death; The first and second dose of vaccine was administered on 28Mar2021 12:00 PM.; The first and second dose of vaccine was administered on 28Mar2021 12:00 PM.; This is a spontaneous report from a contactable consumer. A 79-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; lot: EN6199) and second dose (lot: ER8730); both via an unspecified route of administration into the right arm on 28Mar2021 12:00 for COVID-19 immunization. Medical history included coronary artery disease (CAD), hypertension, parkinson''s disease, abdominal aortic aneurysm, cerebral aneurysm and arthritis. Concomitant medications included paracetamol (TYLENOL) taken for arthritis and a pill for his hypertension. It was reported that the first and second dose of vaccine was administered on 28Mar2021 12:00 PM. The patient''s sudden death on 30Mar2021 15:30 was also reported. An autopsy was not performed. The patient was not diagnosed with COVID-19 prior to vaccination. Further information has been requested.; Reported Cause(s) of Death: Sudden Death


VAERS ID: 1192116 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-20
Onset:2021-03-28
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-04-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021385447

Write-up: Had his first vaccination of the Pfizer and 8 days later he passed away; This is a spontaneous report from a contactable consumer. A male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on 20Mar2021 at single dose for COVID-19 immunisation. Medical history and concomitant medications were unknown. It was reported that the patient had his first vaccination on 20Mar2021 and 8 days later (on 28Mar2021) the patient passed away. It was unknown if an autopsy was performed. Information about lot/batch number has been requested.; Reported Cause(s) of Death: Had his first vaccination of the Pfizer and 8 days later he passed away


VAERS ID: 1202478 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-03-09
Onset:2021-03-28
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose normal, Cardiac arrest, Cardio-respiratory arrest, Dyspnoea, Resuscitation, Ultrasound scan abnormal, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Aspiring, carvediolo, diclofenac, pantoprazole, spironolactone, sucralfate,
Current Illness: Hypertension
Preexisting Conditions: Hypertension, PUD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is a 61 year old female, with history of hypertension, who presents to the ED via EMS for evaluation of cardiac arrest prior to arrival. Patient''s husband came from anouther [sic] room and found patient take a big gasp then suddenly became unresponsive. EMS gave patient a total of 4 rounds of Epi, 1 Narcan, and 2 shocks en route. EMS reports with glucose level of 92. Unknown if patient is on any anticoagulation. Patient presents in asystole. Epi and bicarb given. Compressions performed. Lungs equal with bagging. Bedside US performed which did not reveal any meaningful cardiac activity. Code called. Discussed with family, they state she had been having some cardiac issues and her daughter died of cardiac problems in her 30s.


VAERS ID: 1207001 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-11
Onset:2021-03-28
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805028 / 1 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Upon request
Current Illness:
Preexisting Conditions: Diabetes Kidney disease Heart disease
Allergies: None
Diagnostic Lab Data: Ct scan
CDC Split Type:

Write-up: Intracerebral hemorrhage


VAERS ID: 1207863 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-18
Onset:2021-03-28
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death within 60 days of receiving the COVID vaccine series


VAERS ID: 1207994 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-26
Onset:2021-03-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   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: Cyst on Groin, shingles
Preexisting Conditions: HBB, stage IV Kidney Failure, Diabetes
Allergies: No
Diagnostic Lab Data: Death
CDC Split Type:

Write-up: Blood Clot on back of leg


VAERS ID: 1211052 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-13
Onset:2021-03-28
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / UNK UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Aspiration, Brain stem syndrome, Cerebrovascular accident, Chest X-ray, Chest pain, Computerised tomogram, Death, Dizziness, Dysphagia, Dyspnoea, Gait inability, Hypoaesthesia, Magnetic resonance imaging, Mechanical ventilation, Paralysis
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (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), Dystonia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Vestibular disorders (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetic
Preexisting Conditions: Diabetic
Allergies: Sulfur, penicillin
Diagnostic Lab Data: March 29, 2021 - Chest X-ray, MRI & CT SCANS
CDC Split Type:

Write-up: My father received his shot on March 13, 2021. He drove to move home and on March 28th started having his right arm go numb but did not tell us. He asked to go the ER March 29th at 6:45am saying his chest hurt and was having a hard time breathing, this has happened before since having Covid in September. I called 911 after he became dizzy and could not walk. While at the ER suffered a massive stroke that paralyzed him from his nose down over a course of 3 days. His brain stem was affected and he lost the ability to swallow. After being on a ventilator for 72 hours he was removed from it and died less then 30 mins later from drowning in his own saliva on April 1, 2021.


VAERS ID: 1211001 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-03-22
Onset:2021-03-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 6202 / 1 RA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER 8727 / 2 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Brain injury, Cerebral thrombosis, Cerebrovascular accident, Death, Endotracheal intubation
SMQs:, Angioedema (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), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 8
Permanent Disability? No
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:
Current Illness:
Preexisting Conditions: High blood pressure; diabetes
Allergies:
Diagnostic Lab Data: 03/28. Flown to another state after suffering a massive stroke due to a blood clot in the brain 03/29. Put into surgery to try to relieve pressure on her brain due to the blood clot. 04/2. Removed breathing tube due to 80% brain loss. 04/05. Mom died. My kids found her while she was having the stroke and called 911 on 03/28.
CDC Split Type:

Write-up: Patient is deceased. Had a blood clot travel to her brain and causes an un recoverable stroke


VAERS ID: 1213291 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-03
Onset:2021-03-28
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

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:

Write-up: Was informed at the time the client was to be seen for booster dose of COVID vaccine that he had recently passed away. Unable to contact family for more Information.


VAERS ID: 1216264 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-01-26
Onset:2021-03-28
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation
SMQs:, Anaphylactic reaction (broad), Angioedema (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), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 10
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: depression, hyperlipidemia
Preexisting Conditions:
Allergies: penicillin, shellfish,
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted 3/28/2021 with severe COVID 19 pneumonia. She progressed to acute respiratory failure and was intubated. During her hospitalization she was diagnosed with acute myeloblastic leukemia. Her family withdrew care and she died on 4/7/2021


VAERS ID: 1228018 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-19
Onset:2021-03-28
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Deceased 3/28/21 "natural causes" Narrative: Per notes "Pathologist was informed that he died of natural causes". PCP indicated that death cert will only show HTN as cause of death.


VAERS ID: 1225942 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-19
Onset:2021-03-28
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Laboratory test, Lung assist device therapy, Oral contraception, Pulmonary embolism, Resuscitation
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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Reported to be on Drospirenone-Ethinyl Estradiol 3-0.02 MG per tab
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was a 16yr female who received Pfizer vaccine 3/19/21 at vaccine clinic and presented with ongoing CPR to the ED 3/28/21 after cardiac arrest at home. Patient placed on ECMO and imaging revealed bilateral large pulmonary embolism as likely etiology of arrest. Risk factors included oral contraceptive use. Labs have since confirmed absence of Factor V leiden or prothrombin gene mutation. Patient declared dead by neurologic criteria 3/30/21.


VAERS ID: 1228974 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-11
Onset:2021-03-28
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: CLOPIDOGREL, FAMOTIDINE, HYDRALAZINE, MYCOPHENOLATE, CYCLOSPORINE, DIVALPROEX, LISINOPRIL, AMLODIPINE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT GOT FIRST DOSE OF MODERNA ON 03/11/21 AND PASSED AWAY ON 03/28/2021


VAERS ID: 1256946 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-15
Onset:2021-03-28
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP7534 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Lamotrigene Levetiracetam Aspirin Atorvastatin Lisinopril
Current Illness: None known
Preexisting Conditions: epilepsy, hypertension, hyperlipidemia
Allergies: None known
Diagnostic Lab Data: none performed - no autopsy was performed
CDC Split Type:

Write-up: Unknown if any immediate reaction. The patient passed away on 3/28/21 approximately 2 weeks from the first dose of the vaccine.


VAERS ID: 1269224 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-27
Onset:2021-03-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 LA / SYR

Administered by: Work       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Feeding disorder, Headache, Influenza like illness, Malaise, Nausea, Pain
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: N/A
Current Illness: Osteoporosis
Preexisting Conditions:
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: My partner felt pain overnight. Then, felt flu like symptoms- plus chills- the next day and night. The following morning at 7:00 am, Patient said that she felt real sick. She also, complained of having a real bad Headache, Not long after that, she felt like throwing up. She tried to throw up. Except, nothing came out and she felt very nauseous because of the vaccine. When she came call to bed, I offered to make her some breakfast to help her feel better. Unfortunately, she felt, too, I''ll to try and eat an food because of the way she felt. So, I laid next to her with the hope that all would be well. Because, the pharmacist who administered the second dose. Assured my partner, that it was normal to feel flu like symptoms the next day. So, we never doubted what the pharmacist advised. All of sudden, she suffered a cardiac arrest in my presence and died in front of me.


VAERS ID: 1273626 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-22
Onset:2021-03-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Bed rest, COVID-19, COVID-19 pneumonia, Death, Endotracheal intubation, Hypertension, Intensive care, Mechanical ventilation, Multiple organ dysfunction syndrome, SARS-CoV-2 test positive, Type 2 diabetes mellitus
SMQs:, Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (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 (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   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: Pt developed symptoms of COVID-19 and was placed on bedrest on 03/28/2021. The patient was sent to local ED on 04/01/2021 and then tested for COVID-19 with a positive result. Patient was intubated and placed on ventilator. Pt. spent 22 days in ICU. Pt expired on 04/22/2021 with cause of death listed as MODS and COVID-19 related PNA. Related causes of death were listed as HTN, DMII, and ARDS.


VAERS ID: 1275910 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-03-27
Onset:2021-03-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP7533 / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Ageusia, COVID-19, COVID-19 pneumonia, Cough, Death, Decreased appetite, Diarrhoea, Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Nausea, SARS-CoV-2 test positive, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Taste and smell disorders (narrow), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 16
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: Apixaban, diltiazem, glipizide, lisinopril, metformin, metoprolol, mycophenolate, pravastatin, tacrolimus
Current Illness:
Preexisting Conditions: Extensive past medical history including type 2 diabetes, renal transplantation on chronic immunosuppression, atrial fibrillation on anticoagulation, hypertension
Allergies: None
Diagnostic Lab Data: COVID-19 positive 3/28/21 in ED.
CDC Split Type:

Write-up: Patient presented to ED on 3/28/21 with the following information: patient reports home daughter was diagnosed with COVID-19 infection a few days ago. For about a week now the patient herself has had severe fatigue, loss of taste, loss of appetite, nausea, vomiting and diarrhea. She denies fevers. She has however had a persistent cough and over the last few days has been short of breath. Tested positive for COVID-19 on 3/27/2021 at outside facility. Last night patient had multiple episodes of diarrhea making her fatigue significantly worse today. Has been drinking a lot of free water. Additionally noted increased cough and shortness of breath. Patient was admitted to the hospital with COVID-19 pneumonia on 3/28/21 and expired on 4/13/21.


VAERS ID: 1282517 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-22
Onset:2021-03-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-05-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, COVID-19, COVID-19 pneumonia, Communication disorder, Disorientation, Gait disturbance, Malaise, Mobility decreased, Oxygen saturation decreased, Productive cough, SARS-CoV-2 test positive
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations: Patient was hospitalized after a FLU vaccine 5 years ago
Other Medications: Blood Thinner, medication for thyroid, blood pressure medication
Current Illness: No Illness at time of vaccination and had a negative covid test on 3/18
Preexisting Conditions: Patient had COPD, kidney disease and heart disease (he had a pacemaker)
Allergies: No allergies
Diagnostic Lab Data: Patient had a Covid Test at the ER and it came back positive on 3/30 but they would not admit him 2x because his oxygen levels did not meet criteria for admission and he was sent home. His oxygen levels fell below 90 and he was taken to a different emergency room where he was admitted on April 4th
CDC Split Type:

Write-up: Patient visited his doctor/pulmonologist on 3/18/21 and had a negative covid test- NO SYMPTOMS Patient became very sick AFTER the Moderna Covid Vaccine was administered on 3/20/21. Within 10 days he developed a serious cough/phlegm, he became weak, disoriented, had a hard time walking/ambulating, lifting his arms and communicating. He was diagnosed with Covid Pneumonia. Patient had underlying conditions (heart, lung and kidney disease)


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