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This is VAERS ID 1002813

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 1002813
VAERS Form:2
Age:91.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-03
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure increased, Cardiac arrest, Death, Heart rate increased, Respiratory arrest, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735


Changed on 5/7/2021

VAERS ID: 1002813 Before After
VAERS Form:2
Age:91.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-03
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure increased, Cardiac arrest, Death, Heart rate increased, Respiratory arrest, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735


Changed on 5/14/2021

VAERS ID: 1002813 Before After
VAERS Form:2
Age:91.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-03
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure increased, Cardiac arrest, Death, Heart rate increased, Respiratory arrest, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735

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