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This is VAERS ID 1010114

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1010114
VAERS Form:2
Age:58.0
Sex:Male
Location:Guam
Vaccinated:2021-01-28
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC 'Split Type':

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021


Changed on 5/7/2021

VAERS ID: 1010114 Before After
VAERS Form:2
Age:58.0
Sex:Male
Location:Guam
Vaccinated:2021-01-28
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC 'Split Type':

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021


Changed on 5/14/2021

VAERS ID: 1010114 Before After
VAERS Form:2
Age:58.0
Sex:Male
Location:Guam
Vaccinated:2021-01-28
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC 'Split Type':

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021

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