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This is VAERS ID 1019979

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1019979
VAERS Form:2
Age:72.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-28
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Death, Hypoxia, Oxygen saturation abnormal, Respiratory distress, Tachycardia, General physical health deterioration, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC 'Split Type':

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats


Changed on 5/7/2021

VAERS ID: 1019979 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-28
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Death, Hypoxia, Oxygen saturation abnormal, Respiratory distress, Tachycardia, General physical health deterioration, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC 'Split Type':

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats


Changed on 5/14/2021

VAERS ID: 1019979 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-28
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Death, Hypoxia, Oxygen saturation abnormal, Respiratory distress, Tachycardia, General physical health deterioration, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC 'Split Type':

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats

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