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This is VAERS ID 1022552

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1022552
VAERS Form:2
Age:83.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-14
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of cardiac arrest on 01/21/2021


Changed on 5/7/2021

VAERS ID: 1022552 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-14
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ?   Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ?   Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ?   Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?  
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ?   Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ?   Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ?   Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?  
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of cardiac arrest on 01/21/2021


Changed on 5/14/2021

VAERS ID: 1022552 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-14
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC)   ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension   ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia   ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI   ?
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC)   ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension   ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia   ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI   ?
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of cardiac arrest on 01/21/2021


Changed on 8/20/2021

VAERS ID: 1022552 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-14
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) ? Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension ? Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia ? Other ICD (implantable cardioverter-defibrillator) in place Increased BMI ?
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of cardiac arrest on 01/21/2021

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