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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1012200

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Case Details

VAERS ID: 1012200 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Texas  
Vaccinated:2020-11-28
Onset:2021-01-16
   Days after vaccination:49
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS - / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: GLIPIZIDE, HYDROCHLOROT, JANUVIA, LISINOPRIL, LOVASTATIN, METFORMIN, NOVLOLOG MIX 70/30, SYMLNPEN
Current Illness:
Preexisting Conditions: DMII OPHTH UNCNTRLD, DMII WO CMP NT ST UNCNTR
Allergies:
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: PATIENT''S WIFE REPORTED THAT PATIENT PASSED AWAY ON 01/16/21. BOOSTRIX WAS LAST IMMUNIZATION TAKEN ON 11/26/20 PNEUMAVAX, ONLY RECEIVED REFERRAL PNEUMAVAX RX WAS NEVER RECEIVED


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