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This is VAERS ID 1017212

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1017212
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-06
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF Diabetes
Allergies: Erythromycin, Nabumetone, Zocor, Sulfa drugs
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.


Changed on 5/7/2021

VAERS ID: 1017212 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-06
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF Diabetes
Allergies: Erythromycin, Nabumetone, Zocor, Sulfa drugs drugs
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.


Changed on 5/21/2021

VAERS ID: 1017212 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-06
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF Diabetes
Allergies: Erythromycin, Nabumetone, Zocor, Sulfa drugs drugs
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.


Changed on 7/2/2021

VAERS ID: 1017212 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-06
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? No Yes
   Date died:0000-00-00
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF Diabetes
Allergies: Erythromycin, Nabumetone, Zocor, Sulfa drugs
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.

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