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This is VAERS ID 1006303

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1006303
VAERS Form:2
Age:67.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-28
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: see nursing home record
Current Illness: none
Preexisting Conditions: CVA; HTN; vascular dementia; BPH; neurogenic bladder; COVID positive on 9/12/2020.
Allergies: none
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: death- 2/1/2021


Changed on 5/7/2021

VAERS ID: 1006303 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-28
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: see nursing home record
Current Illness: none
Preexisting Conditions: CVA; HTN; vascular dementia; BPH; neurogenic bladder; COVID positive on 9/12/2020.
Allergies: none none
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: death- 2/1/2021


Changed on 5/14/2021

VAERS ID: 1006303 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-28
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: see nursing home record
Current Illness: none
Preexisting Conditions: CVA; HTN; vascular dementia; BPH; neurogenic bladder; COVID positive on 9/12/2020.
Allergies: none none
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: death- 2/1/2021

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