National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1021040

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1021040
VAERS Form:2
Age:47.0
Sex:Male
Location:Nebraska
Vaccinated:2021-01-06
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-17
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 - LTCF will also be reporting
Current Illness: Unknown - LTCF will also be reporting
Preexisting Conditions: Obesity, others unknown
Allergies: Unknown - LTCF will also be reporting
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Pfizer-BioNTech COVID-19 Vaccine Hospital Emergency Room Provider reported cause of death as COVID vaccine administered 11 days prior to death. Additional information being reported from LTCF.


Changed on 5/7/2021

VAERS ID: 1021040 Before After
VAERS Form:2
Age:47.0
Sex:Male
Location:Nebraska
Vaccinated:2021-01-06
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-17
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 - LTCF will also be reporting
Current Illness: Unknown - LTCF will also be reporting
Preexisting Conditions: Obesity, others unknown
Allergies: Unknown - LTCF will also be reporting reporting
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Pfizer-BioNTech COVID-19 Vaccine Hospital Emergency Room Provider reported cause of death as COVID vaccine administered 11 days prior to death. Additional information being reported from LTCF.


Changed on 5/14/2021

VAERS ID: 1021040 Before After
VAERS Form:2
Age:47.0
Sex:Male
Location:Nebraska
Vaccinated:2021-01-06
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-17
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 - LTCF will also be reporting
Current Illness: Unknown - LTCF will also be reporting
Preexisting Conditions: Obesity, others unknown
Allergies: Unknown - LTCF will also be reporting reporting
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Pfizer-BioNTech COVID-19 Vaccine Hospital Emergency Room Provider reported cause of death as COVID vaccine administered 11 days prior to death. Additional information being reported from LTCF.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1021040&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166