National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1023061

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1023061
VAERS Form:2
Age:74.0
Sex:Male
Location:California
Vaccinated:2021-01-30
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Axillary pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.


Changed on 5/7/2021

VAERS ID: 1023061 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:California
Vaccinated:2021-01-30
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Axillary pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.


Changed on 5/14/2021

VAERS ID: 1023061 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:California
Vaccinated:2021-01-30
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Axillary pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1023061&WAYBACKHISTORY=ON


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