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This is VAERS ID 1026396

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1026396
VAERS Form:2
Age:90.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Ageusia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient experienced loss of taste and lack of appetite. Passed away on 1/23/21.


Changed on 5/7/2021

VAERS ID: 1026396 Before After
VAERS Form:2
Age:90.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Ageusia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown Unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient experienced loss of taste and lack of appetite. Passed away on 1/23/21.


Changed on 5/14/2021

VAERS ID: 1026396 Before After
VAERS Form:2
Age:90.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Ageusia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown Unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient experienced loss of taste and lack of appetite. Passed away on 1/23/21.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1026396&WAYBACKHISTORY=ON


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