National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

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

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

Government Disclaimer on use of this data



Case Details

This is page 9 out of 48

Result pages: prev   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48   next


VAERS ID: 1085302 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-26
Onset:2021-03-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Mechanical ventilation, Metabolic encephalopathy
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   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 oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.


VAERS ID: 1085375 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-02-02
Onset:2021-02-21
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Blood bicarbonate decreased, Blood lactic acid, Blood pH decreased, Blood pressure fluctuation, Cardio-respiratory arrest, Dyspnoea, Endotracheal intubation, Heart rate irregular, Intensive care, PCO2 increased, Pulse absent, Septic shock, Throat tightness, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Toxic-septic shock conditions (narrow), 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), Hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to medical center emergency room on 02/21/2020 at 19:00, patient complained of shortness of breath and feeling fullness of her throat. Patient stated that she had Motrin 800 mg TID and Flexeril PRN due to her back pain. Patient also stated that she ate a banana after she took her medications. Her systolic blood pressure was 50, and her HR was 109, patient also stated that she had her 2 shots of Moderna Vaccine, her first shot was on 01/06 and her second shot was on 02/02. Patient was treated with: 1 Duoneb, 0.3 ML IM of epinephrine, Solumedrol 125 mg, Benadryl IV 50 mg, Normal Saline infusion IV 1000 ml/hr, and Pepcid IV 20 mg. Patient lactic acid was 10.6, WBC 24.2 and Temp 97 F, patient was diagnosed as sepsis shock and patient received: Piperacillin-tazobactam 3.375 g in D5W 50 ml IVPB (3.375 g once) Vancomycin 1 g in D5W 200 ml IVPB (1 g once). Patient pH was < 6.780 and PCO2 was 55 and bicarbonate level was 5.0, patient received Sodium bicarbonate IV 50 mEq once. Patient was not stable as her BP and HR were fluctuating patient received DilTlazem IV 2.5 mg for 2 doses. Patient received Levophed 16 mg /NS 250 ml IV. At 23:13 patient was intubated, patient received a local anesthesia through a central line of lidocaine 2% without epinephrine, and patient was transferred to the ICU to be monitored. At 00:33 CODE BLUE was called and patient became unresponsive and lost pulse while patient was brought to ICU. Patient was coded twice before ROSC, during intubation patient patient noted to have coffee-ground drainage.


VAERS ID: 1085478 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-24
Onset:2021-03-08
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Brain injury, Cardioversion, Computerised tomogram, Critical illness, Echocardiogram abnormal, Fatigue, Intensive care, Laboratory test, Malaise, Pulmonary contusion, Pulmonary haemorrhage, Resuscitation, Rib fracture, Splenic rupture, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Osteoporosis/osteopenia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 5
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: PCN
Diagnostic Lab Data: Multiple CT''s, labs
CDC Split Type:

Write-up: Patient has been feeling fatigued since the vaccine. On 3/8 he went to play Hockey, first time since pandemic started. He reported feeling to his friends that he felt unwell and left the ice. He was found dead, CPR started, EMS called-$g had shockable rhythm (VF), shocked 10 times pre-hospital. Brought to Hospital ER and placed on VA ECMO. He is currently in the ICU setting; echo suggests possible MI but formal cath pending. Has anoxic brain injury, splenic laceration, pulmonary hemorrhage/contusions, rib fractures all related to CPR (received over an hour prior to ECMO placement). Patient may ultimately expire, he is critically ill.


VAERS ID: 1085788 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-22
Onset:2021-02-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Dyspnoea, Lethargy, Respiration abnormal
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin D 10mcg, , Simvistatin 20mg, ferrous sulfate 325 mg, Novolin 20 units a day, Lisinopril 2.5mg
Current Illness: No
Preexisting Conditions: diabetes, hypertension
Allergies: No allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: My grandpa was very lethargic after his 2nd vaccine. The following day he started acting more awake, he had a better appetite but seemed to be breathing a little funny. He was labored a bit. He went to sleep on 2/24/21 and at 230 am was dead.


VAERS ID: 1085865 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-29
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
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: unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: DEATH 2/23/21


VAERS ID: 1086206 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032V20A / 2 UN / -

Administered by: Private       Purchased by: ?
Symptoms: Abdominal discomfort, Malaise, Pain, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 6
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: no
Preexisting Conditions: nothing serious
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: Four days of feeling sick with aches, pains, upset stomach. On day 2 he was so sick he thought he would die. Sudden death on day 7.


VAERS ID: 1086868 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2021-01-17
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / OT

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypotension, Medical device site haemorrhage
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Surgical vascular shunt
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Severe hypotension; Hemodialysis shunt bleeding; A spontaneous report was received from other health professional concerning a 72 years old, male patient who experienced hypotension, removal and replacement of hemodialysis shunt (procedure), hemodialysis shunt bleeding and death. The patient''s medical history was not provided. Concomitant product use was not provided/unknown by the reporter. On 29-DEC-2020, the patient received their first of two planned doses of mRNA-1273 (Batch number [LOT/BATCH: 039K208] intramuscularly in the right arm for prophylaxis of COVID-19 infection. The patient was hospitalized for severe hypotension and Removal and Replacement of hemodialysis shunt from 17-JAN-2021 to 21-Jan-2021. On 26-01-2021 the patient was sent to hospital due to his hemodialysis shunt bleeding. On 27-01-2021, the patient passed away at the hospital . Treatment information was unknown. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1086933 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Body temperature, Chills, Diarrhoea, Feeling abnormal, Myalgia, Nausea, Pneumonia, Pyrexia, Unresponsive to stimuli, Vaccination site pain, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: INSULIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Date: 20210207; Test Name: Body temperature; Result Unstructured Data: Increased
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Pneumonia; Unresponsive at times; Weak; Diarrhea; Feeling Punky; Body aches/muscle aches; Fever; Chills; Nausea; Vomiting; Sore arm at site of injection; A spontaneous report, was received from a nurse (caregiver), regarding a 96 years-old female patient, unknown race and ethnicity, who was administered Moderna''s COVID-19 vaccine (mRNA-1273), and experienced pneumonia, unresponsive at times (unresponsive to stimuli), weak (asthenia), diarrhea, feeling punky (malaise), body aches/muscle aches (myalgia), fever (pyrexia), chills, nausea, vomiting, sore arm at site of injection (vaccination site pain), and vomiting. The patient''s medical history was not reported. Historical vaccine reported was flu shot. Concomitant medications included insulin, unspecified medication for pulmonary hypertension and heart failure. On 05 Feb 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number: 013M20A), intramuscular for the prophylaxis of COVID-19 infection. On 05 Feb 2021, the patient experienced the sore arm. On 07 Feb 2021, the patient experienced body aches, sore arms, felt punky, weak, fevers with a body temperature of 103.7 (unknown units), chills, nausea, vomiting, diarrhea and muscle aches. Treatment medication included acetaminophen. On 08 Feb 2021, the patient continued with high fever, unresponsive at times, and all other symptoms. On 09 Feb 2021, the patient''s fever was control, very weak and passed away on the same day at 04 45 pm. The death occurred and death certificate stated that pneumonia was the cause of death. Action taken with second dose of mRNA-1273 in response to the events was not applicable. The outcome of the event, pneumonia was considered as fatal, and that of other events unresponsive at times, weak, diarrhea, feeling punky, body aches/muscle aches, fever, chills, nausea, vomiting, sore arm at site of injection, and vomiting were considered as unknown. The patient died on 09 Feb 2021. Plans for an autopsy was unknown. The cause of death was reported as pneumonia.; Reporter''s Comments: This case concerns a 96 year old, female patient, who experienced a serious unexpected event of Pneumonia (fatal) among others, 5 days after receiving 1st dose of mRNA- 1273 (Lot# 013M20A). Very limited information regarding these events has been provided at this time. The subject''s con meds included insulin, unknown medications for pulmonary HTN and heart failure. The cause of death was determined to be pneumonia. Advanced age and co-morbidities may remain as risk factors.; Reported Cause(s) of Death: Pneumonia


VAERS ID: 1087763 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-03-05
Onset:2021-03-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Laboratory test, Organ failure
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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes
Allergies:
Diagnostic Lab Data: Numerous.
CDC Split Type:

Write-up: Difficulty breathing leading to organ failure and death


VAERS ID: 1088112 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-02-26
Onset:2021-03-05
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Agitation, Death, Dyspnoea, Dyspnoea exertional, Heart rate increased, Hyperhidrosis, Painful respiration, Pyrexia, Respiratory rate increased, Use of accessory respiratory muscles
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Pulmonary fibrosis CHF
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 03/05/2021: Increased SOB, DOE, increased HR and RR, pain on inhalation, agitation 3/06/2021: increased work of breathing, using accessory muscles, sweats, low-grade fever 3/07/2021- death


VAERS ID: 1088180 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-03-05
Onset:2021-03-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: See Below
Preexisting Conditions: On Hospice due to: Chronic systolic (congestive) heart failure, Chronic kidney disease stage 3, Sick sinus syndrome, Unspecified atrial fibrillation, Presence of cardiac pacemaker, Muscle weakness, Alzheimer''s Disease
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to Hospice on 8/11/20. He experienced normal progression of his diseases until his death on 3/9/21.


VAERS ID: 1088184 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-06
Onset:2021-03-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide, Omeprazole, Xarelto, Vitamin D3, Propranolol, Sucralfate, Spironolactone
Current Illness: Unknown
Preexisting Conditions: Seizures, unknown
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pronounced dead on 3/9/21 approximately 72 hours after receiving vaccination. Unknown symptoms prior.


VAERS ID: 1088287 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-09
Onset:2021-03-05
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Disorientation, Feeling abnormal, Respiratory disorder
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Temazepan 30 mg, Dexin, Bupropion, Sertraline 50 mg, Clonazepam, Difenhidramina 50mg, Valsartaan, Metroprolol, Omega 3, Nifedipine
Current Illness: None
Preexisting Conditions: High blood pressure, Alzheimer, cardiovascular disease, had suffer from heart failure
Allergies: None were reported
Diagnostic Lab Data:
CDC Split Type:

Write-up: The caregiver on duty tells the nurse in charge that on 5/3/2021 she proceeds to bathe the resident and he was disoriented, so she goes to bed at around 5:00 a.m. The resident expresses that he feels bad, when the caregiver goes to look for things to take vital, when he returns she finds him without vital signs and was presenting respiratory problems.


VAERS ID: 1088328 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-04
Onset:2021-02-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Zoloft, Donepezil, Lanoxine, Furosemide, Imdur, Cozaar, Aldactone, Coreg, Pestoril, Pepcid
Current Illness:
Preexisting Conditions: Heart Failure, Hypertension, Osteoporosis, Memory Loss
Allergies: None were reported
Diagnostic Lab Data:
CDC Split Type: Pr-52-21

Write-up: The caregivers in their rounds indicates that resident was well, ate his meals and her vitals were taken. In their next 7:30 pm rounds they find that the resident was not breathing. Home physician certifies death as Congestive Heart Failure.


VAERS ID: 1088367 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-04
Onset:2021-02-24
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Synthroid, Prilosec, Imdur, ASA, Valium, Lipitor, Toprol, Vitamin d3 10,000 Units, Remeron, Restoril, Fosamax, Norvasc, Iron vitamin, Buspar, Seroquel
Current Illness:
Preexisting Conditions: Hypothyroidism, Diabetes, Osteoporosis, Chronic Ischemic Heart Disease, Bedridden
Allergies: None were reported
Diagnostic Lab Data:
CDC Split Type: PR-53-21

Write-up: Person of contact spent around 10 minutes in the room, spoke with the resident, left the room. When the caregiver came into the room with the resident lunch the resident was without vital signs. Dxn: Atherosclerotic Heart Diseases


VAERS ID: 1088539 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-02-11
Onset:2021-02-24
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Muscle rigidity, Peripheral coldness, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lactulose 22.5 ml tid; omeprazole 40 mg daily; rifaximin 550 mg bid
Current Illness: end stage liver disease due to alcoholic cirrhosis with undiagnosed liver mass; chronic hepatitis C.; and hepatic encephalopathy
Preexisting Conditions: alcoholism; hepatitis c with end stage liver disease and hepatic encephalopathy, macrocytic anemia, poly-substance abuse, non-compliant with medical treatment
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: He was found unresponsive, cold and with rigor mortis present after family requested welfare check. He had not been seen for 36 hours.


VAERS ID: 1088615 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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: Carotid Artery Bruit, Smoker, HTN, family hx of cardiovascular disease Sister MI at 56. 11/2015 Abnormal Stress Echo with elevated values on a lipid profile after c/o chest pain. Other medical history unknown.
Allergies: Morphine, Allegra, and Bee Stings
Diagnostic Lab Data: None available
CDC Split Type:

Write-up: Death within 30 days of vaccination, vaccinated on 3/5/2021 pronounced dead on 3/6/2021. Unknown if any side effects from vaccine. No ER visit found at local hospital.


VAERS ID: 1088686 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-03-07
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt found deceased in home on 03/07/2021


VAERS ID: 1088830 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-03
Onset:2021-03-08
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin Vitamins Calcium
Current Illness:
Preexisting Conditions: Diabetes Blood pressure
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died after feeling unwell for about ten minutes.


VAERS ID: 1088837 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-10
Onset:2021-03-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Blood bicarbonate decreased, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose increased, Blood magnesium increased, Blood pH decreased, Blood potassium normal, Blood sodium normal, Blood urea increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Continuous positive airway pressure, Death, Dyspnoea, Endotracheal intubation, Foaming at mouth, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, PCO2 increased, PO2 decreased, Platelet count increased, Pneumothorax, Protein total normal, Pulmonary oedema, Respiratory distress, Unresponsive to stimuli, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Lactic acidosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (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), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol, alprazolam, amlodipine, aspirin, bumetanide, vit D, clopidogrel, escitalopram, ezetimibe, fenofibrate, ferrous gluconate, insulin aspart, insulin glargine, metoprolol tartrate, multivitamin, potassium chloride, ranolazine, rosuva
Current Illness: chronic conditions only noted - most recent was a TAVR procedure completed on 11/20/2020
Preexisting Conditions: Diabetes mellitus, essential hypertension, hyperlipidemia, obstructive sleep apnea, arthritis, fatty liver, renal insufficiency, gallstones, morbid obesity, aortic valve replacement, pulmonary hypertension, CKD stage 3, anxiety, anemia
Allergies: hydrocodone-acetaminophen (hallucinations), nitrofurantoin (unknown)
Diagnostic Lab Data: Chest x-ray 3/10/21 at 11:43am - "Intubation of the right mainstem bronchus. Bilateral pulmonary edema." Chest x-ray 3/10/21 at 1:39pm - "Moderate sized pneumothorax on the right. ET tube has been repositioned." Arterial Blood Gas 3/10/21 at 11:38am - pH <6.811, pCO2 90.7, PO2 78.4, HCO3 13 Chemistry Profile 3/10/21 at 11:46am - Na 143, K 3.9, Cl 106, CO2 15, BUN 32, SCr 1.7, Glc 488, Ca 9.2, Mg 2.3, P 7.1, AST 24, ALT 19 CBC 3/10/21 at 11:46am - WBC 9.9, Hgb 9.3, HCt 33.0, Plt 416
CDC Split Type:

Write-up: Patient received first vaccine dose on 3/10/21, waited for approximately 1 hour in Pharmacy after. Was walking to her vehicle and became short of breath. Patient got to her vehicle and called 911 due to severe shortness of breath. Rescue arrived on scene at approximately 11:00am, found patient in distress and administered epinephrine, methylprednisolone, and diphenhydramine. Patient placed on CPAP in rescue en route to ER, became unresponsive, frothing pink sputum. Intubated by paramedics en route with iGel device. Patient arrived to ER at 11:22am, went into cardiac arrest at 11:24am. Patient continued to be unstable, had multiple rounds of cardiac arrest and ROSC. Patient ultimately did not survive arrests, and pronounced dead at 2:37pm. Medications received during course in the ER - epinephrine 1mg x18 doses, sodium bicarbonate 50mEq x4 doses, calcium chloride 1g, insulin regular 10 units x1, furosemide 80mg x1, epinephrine titrated infusion, sodium bicarbonate infusion.


VAERS ID: 1088956 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-03
Onset:2021-02-14
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: No
Current Illness: No
Preexisting Conditions: Diabetes
Allergies: No
Diagnostic Lab Data: 02/14/2021: Covid-19 test positive and hospitalized hospital
CDC Split Type:

Write-up: Tested positive and had symptoms for Covid-19 . Admitted to hospital on 2/14/21 in the icu and died in 2/28/21


VAERS ID: 1089038 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-27
Onset:2021-01-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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 died 2 days after COVID vaccination, concern for vaccine related death. Autopsy showed bilateral pulmonary emboli. No evidence death was vaccine related.


VAERS ID: 1089215 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNK / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Spiriva
Current Illness: COPD, hypotension, syncope
Preexisting Conditions: COPD, hypotension, syncope
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Syncopal episode followed by death. Unable to be revived. Coroner''s case.


VAERS ID: 1089349 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 24
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: None
CDC Split Type:

Write-up: Patient had an adverse reaction to her first shot, unreported, mostly local to the injection. For this 2nd dose, she was not feeling well the day after the shot, but was at work. She did not show up for work on Friday and was found dead. Time of death was undetermined. She lived alone. An autopsy was not performed.


VAERS ID: 1089441 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-01
Onset:2021-02-21
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Dysphonia, Dyspnoea, Intensive care, Malaise, Mechanical ventilation, Medical induction of coma, Restlessness, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Parkinson-like events (broad), 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: 2021-02-25
   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: Blood pressure.
Current Illness:
Preexisting Conditions: Still a smoker when she died but they x-rayed her and did not see any cancer.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sunday, Feb 21, 2021. Patient told her husband she didn?t feel well and she lay down next to him. She was tossing and looked like she was trying to get up. He was talking to her and she wasn?t answering him. She was having trouble breathing. Took her to the hospital right away at 7:30 pm. They put her into a comma with a respirator. Finally went from emergency room to ICU on Monday. Then on Wednesday they took the respirator out and I spoke to her ? told her we all love her and she could only say hoarsely ?terrible, terrible.? They said she might get moved to regular floor. But then Wednesday night couldn?t breathe again and put the respirator back in. Thursday morning husband had it removed and she died that evening at 10:51 on February 25.


VAERS ID: 1089536 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-12
Onset:2021-02-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 AR / SYR

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: 2021-02-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, CoQ10, fish oil, hydrochlorothiazide, lovastatin, multivitamin, saw palmetto, vitamin d3
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA Heart attack Death


VAERS ID: 1089759 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-01
Onset:2021-02-12
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1303655 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Brain death, Cardiac arrest, Chills, Computerised tomogram, Death, Fall, Nausea, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Centrum Silver(men''s), Osteo BiFex, Vit.C&D3; Atorvastatin 10 mg 1 once a day; Cartia 12-mg 1 once a day; Digoxin 125 mcg 1 tab a day; Eliquis 5 mg1 tab 2x a day; furosemide 40 mg tab 2 x a day; meclizine 25 mg tab, 1 3x a day; metoprolol
Current Illness: None
Preexisting Conditions: Afib, High Blood Pressure
Allergies: None
Diagnostic Lab Data: CT Scan done 2/4/21
CDC Split Type:

Write-up: Fever, chills, nausea the morning After vaccine. Took out the trash and had a cardiac arrest and fell. 911 called went to hospital 3 1/2 days no change. 2 Dr.s said no improvement brain dead. Had a living will disconnected after 48 hrs. Disconnected at 7:00 pm died 8:17 pm. 2/7/21


VAERS ID: 1090182 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Tennessee  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; A spontaneous report was received from a consumer concerning a male patient of unknown age, who was received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history was not provided. No concomitant medications were reported. On an unknown date, prior to the onset of event, the patient received their first of two planned doses of mRNA-1273 (Lot number: unknown) intramuscularly for prophylaxis of COVID-19 infection. It was reported by the patient''s wife that the patient died. She was calling to cancel his second dose of mRNA-1273. No additional details, including the date of death, were reported. Treatment information was not provided. Action taken with the mRNA-1273 was not applicable as the patient died. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. No further information is expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1090369 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-24
Onset:2021-02-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Nausea
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: 2021-02-25
   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: No
Preexisting Conditions: No
Allergies: Penicillin
Diagnostic Lab Data: No such actions were made.
CDC Split Type:

Write-up: Patient showed reaction to vaccine almost immediately, began having chills and nausea. Patient ultimately succumbed to cardiac arrest.


VAERS ID: 1090464 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-10
Onset:2021-02-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ? / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Ageusia, Aggression, Asthenia, Blood test, COVID-19 pneumonia, Chest X-ray, Computerised tomogram thorax, Confusional state, Cough, Death, Decreased appetite, Fall, Mechanical ventilation, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (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 (narrow), Hostility/aggression (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 18
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: Protonix, Crestor, Aspirin, Metroprolol, Wellbuterin, Grapentin, Clonazepam
Current Illness: Heart disease, Hyperlipidemia, Low B/P, Insomnia, one kidney (had donated one), Auto immune disease, Anxiety, Depression, some incontinence possibly due to enlarged prostate, Hydrocele, Morton''s neuromas, poor circulation, ?GERD
Preexisting Conditions: All the above.
Allergies: ?
Diagnostic Lab Data: I know he had a chest x-ray in the ER on day of admission. He had lots of blood work. He had a CT Scan of chest.
CDC Split Type:

Write-up: Feb. 10: Moderna Vaccination #1 Administered (arm) Feb. 11-Feb. 19: Developed a cough which worsened, weakness, confusion, could not follow instruction, fell, no appetite, fever of 102.8 on Feb. 19, no taste Feb. 20: Emergency Room with diagnosis of Covid pneumonia. Given usual Covid treatment. Became very confused, combatative, etc. Feb. 21: Placed on ventilator Mar. 1: Ventilator removed. Patient expired.


VAERS ID: 1091138 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-03-10
Onset:2021-03-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, 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: 2021-03-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL INHALE 2 PUFFS BY MOUTH EVERY 4 HOURS AS NEEDED VALSARTAN ***ARB-2ND LINE*** TAB 320MG TAKE ONE TABLET BY MOUTH EVERY DAY ATORVASTATIN***LIPID-1ST LINE
Current Illness: Pt was just hospitalized for the following issues: NSTEMI, LE ischemia. acute diastolic HF, bilat iliac stents.
Preexisting Conditions: NSTEMI GERD HTN laryngeal cancer COPD
Allergies: BUDESONIDE/FORMOTEROL OLODATEROL/TIOTROPIUM
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt returned to his skilled nursing facility after his 2nd covid vaccine and at approx 10:45 pm he was in cardiac arrest. CPR was started and transported to Hospital. Pt was pronounced dead at 1:06 am on 3/11/21


VAERS ID: 1091158 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-23
Onset:2021-03-06
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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 passed away with in 60 days of receiving the COVID vaccine series


VAERS ID: 1091269 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-04
Onset:2021-02-12
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cerebrovascular accident, Death, Mechanical ventilation
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 14
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: Aranesp, Amlodipine, Aspirin, Eliquis, Furosemide, Nephrocaps, Tamsulosin, Vitamin D, Renvela, Senna, Tessalon Perles
Current Illness:
Preexisting Conditions: ESRD, Meniere''s Disease, Atrial Fibrillation, Coronary Artery Disease, Hypertension, Renal Osteodystrpphy Secondary Hyperparthyrodism, Anemia, BPH
Allergies: Sulfa, Vancomycin
Diagnostic Lab Data:
CDC Split Type:

Write-up: A home dialysis patient who received his first COVID-19 (Moderna) vaccine on 2/4/2021. He was screened prior to admission into the clinic and reported no signs of symptom of COVID-19. This patient was diagnosed with COVID-19 on 2/12/2021 and hospitalized on 2/16/2021 with COVID pneumonia. The patient''s spouse and son (who lives with them) also tested positive for COVID-19. This patient developed COVID-19 complications while inpatient including stroke and mechanical ventilation was required. The patient was made a DNR by family and removed from mechanical ventilation and expired on 2/26/2021.


VAERS ID: 1091327 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Not sure
Current Illness: Not sure
Preexisting Conditions: Not sure
Allergies: Not sure
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1091337 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-03
Onset:2021-02-13
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: atenolol, azelastine, cannabidiol, nexium, haloperidol, hydralazine, norco, hyoscyamine, xopenex HFA, lorazepam, mirtazapine, morphine oral solution, multivitamin, nifedipine, oxygen, senna, tumeric, umeclidinium-vilanterol, magic mouthwash
Current Illness: COPD, diastolic heart failture, mesenteric ischemia, stage III chronic kidney disease, osteoporosis, coronary artery disease with angina
Preexisting Conditions:
Allergies: cephalexin - hives yerba mate - hives, itching boniva - hip pain
Diagnostic Lab Data: none
CDC Split Type:

Write-up: This is a hospice patient. She died on 2/13/2021 from her underlying medical conditions. I just received notification of the death 3/11/2021 and am reporting this immediately.


VAERS ID: 1091439 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram abnormal, Death, Dementia, Fall, Haemorrhage, Loss of consciousness, Mechanical ventilation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: dementia, type 2 diabetes diet controlled, hypothyroidism
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: fell/passed out (unknown) at home, taken by ambulance to local hospital, small bleed noted on CT scan, transferred to tertiary care center, f/u scan after 6 hours unchanged. Sent home. next morning unresponsive, transported back to tertiary care center. required ventilation en route.. massive cerebral hemorrhage noted on CT scan in different area. due to advanced dementia and unresponsiveness life support removed around 9pm that night. passed away at 9am on 3/1.


VAERS ID: 1091538 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-09
Onset:2021-03-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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, Novolog, Lantus, Isosorbide, Losartan-HCTZ, Atorvastatin, Omeprazole, Furosemide
Current Illness:
Preexisting Conditions: Diabetes, hypertension, high cholesterol, gastroesophageal reflux disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: According to his daughter, patient did not appear to have any ill effects from his second COVID-19 vaccine on 03/09/2021. However, on 03/11/2021, he suffered what is suspected to be a fatal arrhythmia/myocardial infarction. It is unknown if there is any correlation to the vaccine.


VAERS ID: 1091560 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-22
Onset:2021-01-26
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Balance disorder, Blood test, Craniotomy, Fall, Haemoglobin decreased, Internal haemorrhage, Magnetic resonance imaging abnormal, Subdural haematoma
SMQs:, Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: sertraline 100 mg, rousuvestatin 20 mg, trazedone, aspirin 81 mg, vitamin D3, Fiber Gummies, Melatonin 2.5, Big Red 500 mg,
Current Illness: None.
Preexisting Conditions: Dementia, stents, high cholesterol treated, mild hearing loss.
Allergies: none
Diagnostic Lab Data: complete medical records are available at clinic including MRI''s, blood tests, etc.
CDC Split Type:

Write-up: On January 26, patient lost his balance and fell, no injury. On January 28, patient, fell, no injury. In both cases falls were observed and were not to the head. On January 29 patient could not maintain his balance. Taken to hospital. MRI revealed large subdural hematoma. Craniotomy on January 30, by Dr. Approximately 10 days later, Hbg, was down to 7, unexplained internal bleeding.


VAERS ID: 1091695 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-03
Onset:2021-02-10
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: no allergies identifiied
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient expired 2/10/2021. Unknown whether the death was even related to the vaccine. Pt did not have any problems during 15 min observation period and no issues reported to HD after vaccination. reported because the person expired within 7 days of vaccination.


VAERS ID: 1091753 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: was on warfarin but other medications unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: allergy to sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: observed for 15 min after both vaccines and no reported issues after vaccination. Patient did expire 2/25/2021 but cause of death unknown.


VAERS ID: 1091894 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-02-25
Onset:2021-03-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dysstasia, Fall, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atenolol, atorvastatin, lisinopril, furosemide, fluticasone-salmeterol, gabapentin, DuoNeb
Current Illness: Congestive heart failure, COPD, hypertension, peripheral edema
Preexisting Conditions: Congestive heart failure, COPD, hypertension, chronic kidney disease stage III, peripheral edema
Allergies: Lovastatin, dust, keawa flower
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient presented to the off complaining of feeling weak in the legs on Monday, March 1, 2021. She had been moving over the weekend and was over-exerting herself and stated she had fallen on a rug at the old house and then had lain down on the floor to sleep with her dog in the new home, had difficulty getting up and needed help. No symptoms of fever, chills, sweats, headache, myalgias. The next day she passed away at her home, sitting in her chair.


VAERS ID: 1091928 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-02-11
Onset:2021-03-08
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Lung neoplasm malignant, No adverse event
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Lung cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was given Moderna COVID-19 vaccine on 2/11/21 with no adverse reactions. Pt later died on 3/08/2021 with lung cancer being cause of death.


VAERS ID: 1091957 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-01-19
Onset:2021-02-19
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Eye contusion, Seizure, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: My dad had a whole list of medications that Nursing home would have
Current Illness: Diabetes Gout
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I''m still not sure which COVID19 vaccine my dad received (It made me fill it out--I''m not sure if he got Moderna or Pfizer). Nursing home would know. He received his 2nd shot on Jan 19. On Feb 17 all was fine and they were planning on getting him crowns at the dentist. On Feb. 19 everything went poorly. He started to suddenly have seizures and was not responsive. When I arrived on Feb 21 he didn''t say much and had seizures that night. On Feb 22, he responded a little bit and had a big black eye from a seizure the night before. On Feb 22 he had at least 4 seizures and he passed that afternoon around 1:20 pm


VAERS ID: 1092016 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-02-05
Onset:2021-02-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, 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: 2021-02-10
   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: Acetaminophen 325 mg, 2 every 4 hours, Allevyn Adhesive Pad (wound dressings), atorvastatin calcium 10mg, diphenhydramine HCl 25 mg, cefdinir 300 mg, digoxin 125 mcg, ellquis tablet 5 mg, levothyroxine sodium tablet 112 mcg, megace oral sus
Current Illness: Severe UTI, dementia.
Preexisting Conditions: T2 diabetes mellitus, essential hypertension, chronic a-fib, osteoarthritis, malignant neoplasm of breast, hypothyroidism, hyperlipidemia
Allergies: Bactrim
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Per son and employee, patient''s health had been declining since she was hospitalized for a severe UTI in Dec 2020. The evening of 02.09.2021 she vomited, then was found to be unresponsive the morning of 02.10.2021. Patient passed away later in the day on 02.10.2021.


VAERS ID: 1092047 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-07
Onset:2021-02-18
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1092108 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-11
Onset:2021-02-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Fatigue, Malaise, Myocardial infarction, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Metoprolol
Current Illness: None
Preexisting Conditions: None (had prior heart surgery two times.)
Allergies: None
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Patient''s wife reports patient never reported feeling unwell. He had been working on painting the basement all week and on 02.12.2021 came in from outside, ate, and they sat down to watch TV. Around 9:30 patient reported being extremely tired and went to bed. Was found unresponsive the following morning, 02.13.2021. Patient''s wife reports the doctor said it was a heart attack.


VAERS ID: 1092110 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-06
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040M20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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 passed away within 60 days of receiving a COVID vaccine series


VAERS ID: 1092168 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-31
Onset:2021-02-12
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1092214 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-02
Onset:2021-03-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol Aspirin Atorvastatin Carvedilol Fish Oil Isosorbide Levemir Insulin Magnesium Metformin Novolog Insulin Omega 3 Potassium Chloride Ranolazine Sildenafil Torsemide Zetia
Current Illness: none documented
Preexisting Conditions: Hypertension Benign neoplastic disease microalbuminuric diabetic nephropathy coronary bypass graft atopic dermatitis angina pectoris acute injury of kidney hyperlipidemia diabetes Myocardial infarction Heart failure atherosclerosis aortic valve stenosis sleep apnea spinal stenosis erectile dysfunction
Allergies: Losartan Simvastatin Amlodipine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his first COVID vaccine on 3/2 and then passed away 3 days after receiving Moderna vaccine. Provider presumed he died from sudden heart attack, this occurred at home.


VAERS ID: 1092328 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 AR / IM

Administered by: Work       Purchased by: ?
Symptoms: Anticonvulsant drug level increased, Blood lactic acid increased, Brain death, Computerised tomogram head normal, Electrocardiogram normal, Electroencephalogram abnormal, Full blood count normal, Magnetic resonance imaging head normal, Resuscitation, Scan with contrast normal, Unresponsive to stimuli
SMQs:, Lactic acidosis (narrow), 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: 2021-02-06
   Days after onset: 5
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: Lamictal 200mg twice daily Keppra 1000mg twice daily Phenobarbital 60 mg 1 tab in morning and 2 tabs in evening
Current Illness: None
Preexisting Conditions: Well controlled Epilepsy since birth
Allergies: Sulfa
Diagnostic Lab Data: 2/1/21 hospital ran full blood work panel, said things were normal. CT of head showed normal test result, EKG normal. 2/3/21 MRI of head was normal-sent to another hospital. Blood work was normal besides elevated Lamical level and elevated lactic acid. Patient took all seizure medications as prescribed prior to event. 2/4/21 MRI with contrast was normal. EEG abnormal,
CDC Split Type:

Write-up: Patient appeared alert, oriented and completed everyday normal activates 3 days after receiving vaccine on a Wednesday afternoon, Jan 27th 2021 at 4:00 p.m. . Went to bed as usual on Sunday night Jan 31st 2021 at 9:30 p.m., husband found patient on couch sitting upright, unresponsive at 4:00 a.m. Patient''s daughter came over to the house approx. 8 minutes later. Preformed CPR for 3-5 minutes, pt had a pulse. The ambulance was called prior to daughter arriving at the house. Ambulance arrived at 4:40 a.m. took pt to Hospital by 5:00a.m. Pt declared "brain dead"


VAERS ID: 1092483 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Fatigue, Headache, Respiration abnormal
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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: Atorvastatin 20mg daily Meloxicam 7.5mg daily Women''s One- A-Day Vitamin daily Famcyclovir 250mg every 3 days Glucosamine Chondroitin 1500/1250 daily Vitamin D-3 2000 IU daily
Current Illness: None noted
Preexisting Conditions: Hyperlipidemia based on medication record
Allergies: Combivent, gabapentin, tramadol.
Diagnostic Lab Data: None noted
CDC Split Type:

Write-up: Both patient and spouse we given their Moderna prime dose on 2-10-21. Both patient and spouse agreed to observe the post vaccination waiting period and reported no concerns. On 3-10-2021, they returned for their boost dose at 12:30 PM. Prior to administration of their second dose, they reported only mild headache and fatigue that presented approximately 12 hours after their first dose was administered. Once again, spouse and patient observed the post vaccination waiting period and reported no issues. On 3-11-21, I was notified that patient had passed away at home. In speaking to spouse, he stated that they both went to bed that evening with with a mild headache and fatigue. Spouse stated that he woke up early that morning with a more pronounced headache and had difficulty sleeping. He noted that at approximately 5:18 AM patient seemed to breathing heavily and may have gasped a bit. He checked on her again around 6:40 and determined that she had passed away. He contacted EMS and the technician confirmed that she had passed away. Spouse reports that the state will perform and autopsy in the next few days at the direction of Medical staff.


VAERS ID: 1092485 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-27
Onset:2021-02-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA COVID MODERNA 0 / 2 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Death, Gait inability, Hypoaesthesia, Malaise, Mobility decreased
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Tendinopathies and ligament disorders (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: Parkinsons Meds maybe glipizide ktab pepcid
Current Illness: Parkinsons Boarderline type 2 diabetes under control
Preexisting Conditions: Parkinsons type two diabetes
Allergies: No known
Diagnostic Lab Data: None were done because he was dead but he had had a procedure done just a week and a half before and there was blood work and other tests done. So there is recent information to look over.
CDC Split Type:

Write-up: Patient felt generally unwell, tired and unable to walk well. Said his feet felt numb. He could not get up and slid to the floor. He did not have the core strength to even help him sit up. Sometime after he was assisted back on the couch around 4:30 am he must of got back up and attempted to go to restroom because he was found on the floor with his arm and face resting on the love seat which looked as if he was trying to pull himself up. His wife found him in the morning around 11:00 am and he had been died for some time according to EMS. His death was unexpected. Even when contacting his doctors they were confused as to why he had passed away. No autopsy was done but as of this moment he has not been cremated yet and is at Funeral Home.


VAERS ID: 1092595 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-01
Onset:2021-02-05
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bronchitis, 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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: A high risk employee received 1st vaccine dose of Moderna through the Health Center (HC) on 2/1/2021. This patient was seen as an employee only and was not established patient of the HC. The patient reported "having symptoms of Bronchititis" on 2/5/2021 prior to being hospitalized for 7 days (2/5/21 to 2/12/21). On 2/12/2021, an ER visit at Medical Center & transported to General Hospital on 2/13/21. On 3/11/2021, we were notified that the patient died on 3/10/21.


VAERS ID: 1092651 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0124214 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: HTN, DM, Cholesterol and blood thinners
Current Illness: +Covid in January 2021
Preexisting Conditions: Cardiac
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: DEATH


VAERS ID: 1092653 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-09
Onset:2021-03-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin B12,C,D3. Eyedrops, probiotics
Current Illness: Bladder cancer, Malignant melanoma, both in remission
Preexisting Conditions: Interstitial cystitis, mitral valve prolapse, aortic calcifications consistent with asymptomatic atherosclerotic vascular disease.
Allergies: robitussin
Diagnostic Lab Data: Patient expired.
CDC Split Type:

Write-up: Patient received the vaccine on the evening of 03-09-2021. R.N. states she was "fine " at 440 AM bed check. At 0830 03-10-2021 patient was found slumped over on her bathroom toilet having expired sometime between 440AM and 830 AM


VAERS ID: 1092737 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-02-27
Onset:2021-03-11
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / UN

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: 2021-03-11
   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: Levothyroxine Insulin Diabetes meds
Current Illness:
Preexisting Conditions: Diabetes, coronary artery disease, hypothyroidism
Allergies: None known
Diagnostic Lab Data: Ambulance personnel pronounced dead at scene
CDC Split Type:

Write-up: Sudden death. Alone at home, found on floor 4 hours after last phone contact


VAERS ID: 1092941 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Dyspnoea, Fatigue
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Trazodone 50mg tablet Alprazolam 0.25mg tab Xarelto 15mg tablet Metoprolol Succ ER 50mg tab ER24hr Donepezil HCL f/c 10mg tablet
Current Illness: Diagnosed with COVID 19 by Atlas Lab. I was contacted Dec 24, 202O. I was allowed to see her on Dec 26 and found her with very mild symptoms (maybe none at all.)
Preexisting Conditions: Dementia Hodgkins Lymphoma - diagnosed in 2006 - No treatment
Allergies: None
Diagnostic Lab Data: None due to age
CDC Split Type:

Write-up: Extreme fatigue, shortness of breath. Stopped eating within 2 days, stopped fluid intake 3 days later. Family notified on March 3. ery little fluid intake until Sun, when fluid intake stopped as well. Death occured on mon, Feb 8 2021.


VAERS ID: 1303694 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-27
Onset:2021-02-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Military       Purchased by: ?
Symptoms: Asthenia, Death, Fall, General physical health deterioration
SMQs:, Guillain-Barre syndrome (broad), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Citalopram, famotidine, Lasix, KCL, Levothyroxine, Metoprolol
Current Illness: Vascular Dementia
Preexisting Conditions: Parkinson
Allergies: Ativan Lipitor
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt started feeling weak within hours of vaccine progressive weakness ensued and pt began to have falls and Rapid decline in general status and Died 3- -2021


VAERS ID: 1093418 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-27
Onset:2021-02-24
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Choking, Cough, Death, Dysphagia, Dyspnoea, Gait disturbance, General physical health deterioration, Loss of consciousness, Mechanical ventilation, Positron emission tomogram, Posture abnormal, Pulse absent, Resuscitation, Walking aid user, Wheelchair user
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (broad), Parkinson-like events (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), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nat available at this time
Current Illness: In January 2021, pt had a follow up PET scan with his oncologist, and that was reported as clear , with no signs of lung cancer. Pt had been treated for stage 3 lung cancer in January and February of 2020.
Preexisting Conditions: Adult onset hypertension; COPD seconda;ry to Lung Cancer dx in 11/2019.
Allergies:
Diagnostic Lab Data: PET SCAN of lungs in January, 2021, with no signs of lung cancer present
CDC Split Type:

Write-up: After pt received first dose of Moderna on January 27, 2021, he experieced continuous increased decline in his health , with symptoms of increased difficulty swallowing, increased coughing, at least one episode of choking with expulsion of food; increased difficulty walking with walker, increased shortness of breath. On Wednesday, Feb. 24, at 7:50 a.m. , Pt was in wheelchair exiting home, on way to detached garage, being pushed by his daughter, when he slumped over, stated that he couldn''t breathe, and went unconscious. Pt. did not have a detectable pulse . EMT was called and upon arrival performed CPR and obtained a pulse. Pt was transported to local hospital, where, again he lost pulse and was resuscitated again with mechanical CPR. Pt was supported with blood pressure medicine and ventilator until 7:53 p.m. when his heart stopped again. Pt. passed at that time.


VAERS ID: 1093666 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-21
Onset:2021-01-28
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client Passed away on 1/28/2021


VAERS ID: 1093843 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-12
Onset:2021-02-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: no known allergies
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: patient''s daughter reported patient passed away 2 days after first dose of vaccine


VAERS ID: 1093986 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: No
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Received a phone call stating that the patient complained of not feeling well on 3/11/21 while at work and that the patient died that night while at home.


VAERS ID: 1094102 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-27
Onset:2021-02-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 2 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood test, Death, No adverse event, Toxicologic test, Urine analysis
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: TOXICOLOGY, URINE & BLOOD
CDC Split Type:

Write-up: NO ADVERSE EVENT NOTICE RECEIVED ON DATE OF VACCINE. RECEIVED NOTICE FROM CORONOER THAT THIS PATIENT EXPIRED 2/28/2021. COLLECTED URINE, BLOOD, AND TOXICOLOGY SCREEN. NOT SENT TO HOSPITAL. SENT TO FUNERAL HOME


VAERS ID: 1094164 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-03-01
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 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: 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: deceased


VAERS ID: 1094165 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest pain, Death, Nausea, Resuscitation, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received her first dose of the Mederna Covid vaccine at the Health unit on 03/10/21. Her family states she began experiencing nausea and vomiting last night (03/11/2021) and then started having chest pain at around midnight. This morning (03/12/2021) she was still experiencing vomiting and chest pain. She collapsed at approximately 07:30 and her family initiated CPR and EMS was called. She was brought the Hospital via Ambulance at 08:18 in cardiac arrest. The emergency department was unable to resuscitate her and she was pronounced dead.


VAERS ID: 1094197 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-26
Onset:2021-03-11
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ500AB / 1 LA / IM
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. T033663 / 1 LA / IM
VARZOS: ZOSTER (SHINGRIX) / GLAXOSMITHKLINE BIOLOGICALS ZJ432 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Feeling abnormal
SMQs:, Dementia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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: ELIQUIS, LASIX, PROTONIX,ALTACE, TRADJENTA, LUMIGAN, AMIODARONE, METOPROLOL
Current Illness: UNKNOWN
Preexisting Conditions: HBP, DIABETES, MAY BE OTHERS
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN - CONTACT PHYSICIAN OR HOSPITAL I AM NOT AWARE IF HE WAS TAKEN TO HOSPITAL OR DR''S OFFICE YESTERDAY OR NOT.
CDC Split Type:

Write-up: DEATH - PT''S WIFE CALLED 3-11 TO TELL US PATIENT WAS FEELING BAD, AND TO ASK WHAT TO DO. WE SENT A PULSEOXIMETER, AND ADVISED TO CONTACT DR. - ON MORNING OF 3-12, PT''S WIFE CALLED TO TELL US HE HAD PASSED AWAY DURING THE NIGHT.


VAERS ID: 1094208 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-02-05
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Mental status changes
SMQs:, Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ALTERED MENTAL STATUS Death


VAERS ID: 1094290 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-02-23
Onset:2021-03-10
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: B12, Vitamin D, Brea Elipta 200mcg, gabapentin 800mg, Lantus, Loratadine 10mg, Metformin 1,000 mg, Metoprolol 25 mg, losartin 100 mg, Omeprazole 40 mg, Oxycodone 7.5 mg, Paroxetine 20 mg, Pioglitazone 45 mg, Rosuvastatin 40 mg, theophylline
Current Illness: Thyroid, Type 2 Diabetic Hyperlipidemia, Pernicious Anemia, Coronary Artery Disease, Hypertension, High cholesterol, Kidney Disease, Vascular Disease
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died on March 10th 2021 and received the vaccine on February 23 2021. Patient had health issues. Spoke with coroner and patient did die at home. Patient was taken straight the the funeral home afterwards.


VAERS ID: 1094300 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-02-24
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1094402 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-02
Onset:2021-03-01
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: 1094468 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-02-11
Onset:2021-03-04
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Fall, Femoral neck fracture
SMQs:, Accidents and injuries (narrow), Osteoporosis/osteopenia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalization after a fall resulting in femoral neck fracture. Patient deceased 3/4/21.


VAERS ID: 1094600 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-06
Onset:2021-02-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21P / 2 UN / UN

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: It is unknown if the decedent had any side effects. Patient died on 3/11/2021.


VAERS ID: 1094638 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-13
Onset:2021-02-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: COVID-19, Confusional state, Cough, Death, Dehydration, Dialysis, Endotracheal intubation, Exposure to SARS-CoV-2, Mechanical ventilation, Multiple organ dysfunction syndrome, Oxygen saturation decreased, Renal failure, SARS-CoV-2 test positive, Tremor
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), 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), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Jardiance, Metformin, Buproprian, Symbacort, Blood Pressure Medicine, Staten Medication, Zinc, Vitamin C, Vitamin D, Quercetin, Low Dose Baby Aspirin, Melatonin, Performa mist and Albuteral
Current Illness: Ongoing effects of Agent Orange exposure, Asthma, Diabetes Type 2 and High Blood Pressure
Preexisting Conditions: Diabetic, Severe Asthma, Chronic Cough
Allergies: Augmentin and Penicillin
Diagnostic Lab Data: Covid 19 test 2/17 and 2/20/21 with positive results. Hospital records from Hospital from 2/20/21 date of admittance to 2/26/21 date of death
CDC Split Type:

Write-up: Exposure to Covid 19 either on the date of vaccine (2/13/21) or shortly thereafter. Symptoms of Covid started on Monday (2/15) early morning following shot. Dr. ordered Covid test on Weds. (2/17). Taken by ambulance to Hospital, approx. 7 pm on Saturday (2/20) with dehydration, low oxygen levels, confusion, shaking and cough. Admitted to hospital with threats of ventilator up until Weds (2/24) when he was intubated, proned and FINALLY given hydration via IV fluids. He went into kidney failure on Thursday (2/25) and put on dialysis. Other organs began shutting down and was taken off the ventilator on Friday (2/26) and did not recover. He passed away just before 4:00 p.m. on 2/26/21.


VAERS ID: 1094868 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-01
Onset:2021-03-07
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Confusional state, Gait disturbance, Hallucination, visual, Hypoxia, Influenza, Influenza B virus test positive, Respiratory tract congestion, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 5
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Started having confusion at 3#0 a.m. Sunday morning. Unstable gait and hypoxia at home. More congested than usual. Had 2nd COVID vaccine 4 weeks ago. Had visual hallucinations with seeing "bugs" Admitted with positive COVID and Influenza B diagnosis.


VAERS ID: 1094990 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-26
Onset:2021-02-24
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 60 days of COVID vaccine administration


VAERS ID: 1095081 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-21
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1095160 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-02-19
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1095170 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-01
Onset:2021-03-03
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Asthenia, Death, Dyspnoea, General physical health deterioration
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 3
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: Aspirin, furosemide, duoneb, KCL,
Current Illness: COPD
Preexisting Conditions: COPD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient status started to decline within a few hours of receiving her covid vaccine she was weak, developed increased shortness of breath and went to the emergency room were she was diagnosed with STEMI and within 2 days expired.


VAERS ID: 1095238 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-03-08
Onset:2021-03-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dyspnoea, Oedema, Oxygen saturation decreased, Resuscitation, Tachycardia, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix 40 mg daily, Potassium 10 meq daily, Novolin 70/30 insulin, gabapentin 600 mg BID, metformin 500mg BID, Naprosyn 500 mg BID, Lisinopril 20 mg daily, incruse ellipta and fluticasone/ salmeterol inhalers
Current Illness: covid positive 9/14/20, recently worsening of congestive heart failure with edema and shortness of breath for previous week
Preexisting Conditions: sarcoidosis, COPD, diabetes, HTN, congestive heart failure
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient at the time of vaccination on 3-8-21 has having issues with shortness of breath and edema consistent with congestive heart failure, the following day on 3-9-21, he was having more issues with shortness of breath, tachycardia, low O2 saturation. He was given meds in the clinic and monitored until he was feeling better with increased O2 sats. He was found unresponsive on his housing unit one hour later and failed to respond to resuscitation efforts and was pronounced expired at 1047.


VAERS ID: 1095300 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Death, Headache, Nausea, Pain
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   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: not known
Current Illness: not known
Preexisting Conditions: not known
Allergies: nka
Diagnostic Lab Data:
CDC Split Type:

Write-up: According to Medical Center''s report, patient was brought to ED deceased upon arrival via EMS on 03/12/2021 at 8:57am. Patient had been seen on 3/11/2021 at same ED complaining of a heavy type of chest pain in the mid chest, also noting body aches, headache, and nausea.


VAERS ID: 1095393 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Toxicologic test
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: 2021-03-11
   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, Vitamin D
Current Illness: None
Preexisting Conditions: Coronary Artery Disease
Allergies: NKDA
Diagnostic Lab Data: Serum Toxicology Tests Pending
CDC Split Type:

Write-up: Cardiac Arrest


VAERS ID: 1095406 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1095435 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-11
Onset:2021-01-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Dyspnoea, Headache, Nausea, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Embolic and thrombotic events, venous (narrow), 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: 2021-01-27
   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: Atenolol
Current Illness: Feeling nauseated vomiting with headache
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Autopsy- pulmonary embolism
CDC Split Type:

Write-up: Headache, nausea on 1/25 progressed to SOB 1/26 and death 1/27


VAERS ID: 1095456 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-02-15
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-01-30
   Days after onset: 16
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: date of injection 01/30/2021 CARDIAC ARREST 1/30/2021 Death 1/30/2021


VAERS ID: 1095555 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-04
Onset:2021-02-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1095596 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-02-23
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest death


VAERS ID: 1095666 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: COPD Diabetes Cardiovascular Disease Pace Maker
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his 2nd dose of Moderna COVID-19 vaccine yesterday. He was found dead at his home today. After speaking with the County Coroner, an autopsy is not planned. Patient had COPD, Type II Diabetes, cardiovascular disease, and a pacemaker. The coroner does not believe vaccination was contributory to his death.


VAERS ID: 1095725 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-03-07
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1095737 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-02-17
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Death, Dyspnoea, Liver function test abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), 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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Shortness of breath Acute on chronic renal failure Abnormal LFTs Death


VAERS ID: 1095798 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-02-21
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1095862 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-23
Onset:2021-02-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Diarrhoea, Hypersomnia, Hypophagia
SMQs:, Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Depression (excl suicide and self injury) (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Alzheimers
Preexisting Conditions: Alzheimers
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: received a phone call from the daughter of the patient. On 01/21/2021, patient came in and got his first Covid Vaccination. 3 days after the vaccination, the patient experienced really bad diarrhea, and was sleeping for 22 hours a day. 2 weeks later he perked up a little bit. On 02/23/2021, patient received his booster. Daughter states that 2 days later, patient shut down completely, not eating or drinking. The patient ended up passing away on 03/05/2021.


VAERS ID: 1096497 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03621A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Diarrhoea, Fatigue
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Setraline, Methocarbamol, Pantoprazole, Gabepentin, Benztropine, Hydroxyzine, Zyrtec, Ferrous Sulfate, Memantine, Donepezil, Lamotrigine, Fluticasone, Propranolol
Current Illness: Bipolar Disorder, Hypertension, Allergic Rhinitis
Preexisting Conditions: Bipolar Disorder Hypertension Chronic Back Pain
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Notified by police department that patient was found dead at his home on 3/12/21. Per the officer, the family reports patient reported diarrhea on 3/11/21 and fatigue on 3/12/21. The family found him in his home deceased later in the day on 3/12/21


VAERS ID: 1096602 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Death, Decreased appetite, Dizziness, Dyspnoea, Fatigue, Immediate post-injection reaction, Nausea, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Vestibular disorders (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dorzolamide-timolol eye drops, clonazepam, guaifenesin, ipratropium-albuterol, latanoprost eye drops, oxygen 5 liters via nasal cannula, refresh eye drops, ventolin HFA. Also possible hospice medications (atropine drops, haloperidol, loraze
Current Illness: Idiopathic pulmonary fibrosis, asthma, COPD, anxiety, CKD3, macular degeneration, GERD, glaucoma, hypercalcemia, HLD, hypothyroidism, osteoarthritis, migraines, osteopenia, post-menopausal bleeding of undetermined significance, b12 deficiency, vitamin D deficiency
Preexisting Conditions: See illness at time vaccination
Allergies: Tetracyclines (hives)
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Hospice nurse reported patient started experiencing fatigue, nausea, dizziness, decreased appetite and shortness of breath immediately following vaccination. Hospice medications were ordered and patient began receiving morphine and nebulizer treatments. She then started having dysphasia. She then died on 3/5/21 from presumed respiratory failure.


VAERS ID: 1096913 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-24
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Blood pressure decreased, Blood test, Chest discomfort, Death, Dyspnoea, Electrocardiogram, Myocardial infarction
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Simvastatin, Clopidogrel, Aspirin, Losartan
Current Illness: Heart Problem, High Blood Pressure, Arthritis
Preexisting Conditions: Heart Problem, High Blood Pressure, Arthritis
Allergies:
Diagnostic Lab Data: EKG Blood Tests
CDC Split Type:

Write-up: My father passed away on February 10th, 2021. On Monday, January 25th 2021, he said he is feeling very uncomfortable in his chest area. He thought it was severe acid reflux. He took Gas X for Acid Reflux and told us that he does not want to go to the hospital. On Tuyesday, January 26th, he felt that his Acid Reflux symptoms got worse, he still did not want to go to the hospital. He took Tums. On that evening, he started having shortness of breath. We took his BP at home and it was very low. We begged him to go to the hospital, he still did not want to go. On Wednesday, January 27th, his shortness of breath got worse and we convinced him that he has to go to the hospital. We took him to ER. Doctor said that he had a heart attack on Monday morning and that is why he was not feeling well since Monday morning. While at the hospital, while the cardiologists were monitoring him, his heart condition got worse. By Friday, February 5th, cardiologists said that he is very fragile, his heart condition is very fragile and he won''t survive any procedure. They said that something triggered the heart attack. We told them about the vaccination on 1/13/2021. They sent him home on hospice on Friday, Feburary 5th, 2021. He was on supplemental oxygen when he came home. He passed away due to a heart attack on February 10th, 2021 around 9pm.


VAERS ID: 1096952 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-12
Onset:2021-03-02
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0131L20A / 1 RA / IM

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

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

Write-up: Patients cancer progressed quicker than expected. Resulting in his passing


VAERS ID: 1097244 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-08
Onset:2021-02-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death
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: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Atherosclerosis of Aorta, Atrial Fibrillation, unspecified, CKD Stage 3, GERD, Gout, Hypertension, Hyperlipidemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 7 days of vaccine. COD Cardiac Arrest


VAERS ID: 1097283 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-03
Onset:2021-02-11
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Essential hypertension Cardiac arrhythmia Atrial flutter (CMS/HCC) Acute myocardial infarction
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 7 days of vaccine


VAERS ID: 1098041 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-08
Onset:2021-03-12
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Pharmacy       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: None disclosed
Current Illness: None disclosed
Preexisting Conditions: None disclosed
Allergies: Eggs-discussed prior to vaccination no other allergies listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death, reported to pharmacy via Coroner''s office


VAERS ID: 1098119 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-01-22
Onset:2021-02-01
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Death, Diarrhoea, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Adderall 10 MG Common daily vitamin pack Bupropion 150 MG Tramadol 50 MG
Current Illness:
Preexisting Conditions: Fibromialgia Rheumatiod Arthritus
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: in the early am she had bad diarrhea , she went to work and then started having really bad stomach pains and before noon she had to go home because she started puking. She laid down to take a nap around 3:30pm and never woke up.


Result pages: prev   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48   next

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?EVENTS=ON&PAGENO=9&PERPAGE=100&VAX=COVID19&VAXMAN=MODERNA&DIED=Yes


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166