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This is VAERS ID 1023840

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1023840
VAERS Form:2
Age:62.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.


Changed on 5/7/2021

VAERS ID: 1023840 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA NKA
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.


Changed on 5/14/2021

VAERS ID: 1023840 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA NKA
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.

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