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This is VAERS ID 1012200

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1012200
VAERS Form:2
Age:
Sex:Male
Location:Texas
Vaccinated:2020-11-28
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: 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


Changed on 5/7/2021

VAERS ID: 1012200 Before After
VAERS Form:2
Age:
Sex:Male
Location:Texas
Vaccinated:2020-11-28
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: 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


Changed on 5/21/2021

VAERS ID: 1012200 Before After
VAERS Form:2
Age:
Sex:Male
Location:Texas
Vaccinated:2020-11-28
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: 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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