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This is VAERS ID 1023979

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1023979
VAERS Form:2
Age:76.0
Sex:Male
Location:Texas
Vaccinated:2021-02-01
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA
Diagnostic Lab Data: autopsy results are pending
CDC 'Split Type':

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly


Changed on 5/7/2021

VAERS ID: 1023979 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Texas
Vaccinated:2021-02-01
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA NKDA
Diagnostic Lab Data: autopsy results are pending
CDC 'Split Type':

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly


Changed on 5/14/2021

VAERS ID: 1023979 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Texas
Vaccinated:2021-02-01
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
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: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA NKDA
Diagnostic Lab Data: autopsy results are pending
CDC 'Split Type':

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly

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