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This is VAERS ID 1020749

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1020749
VAERS Form:2
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-13
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cyanosis, Death, Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC 'Split Type': MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.


Changed on 5/7/2021

VAERS ID: 1020749 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-13
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cyanosis, Death, Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC 'Split Type': MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.


Changed on 5/21/2021

VAERS ID: 1020749 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-13
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cyanosis, Death, Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC 'Split Type': MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.

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