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This is VAERS ID 1002840

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 1002840
VAERS Form:2
Age:85.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-26
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.


Changed on 5/7/2021

VAERS ID: 1002840 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-26
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None None
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.


Changed on 5/14/2021

VAERS ID: 1002840 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-26
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None None
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1002840&WAYBACKHISTORY=ON

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