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This is VAERS ID 1026443

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1026443
VAERS Form:2
Age:76.0
Sex:Female
Location:Mississippi
Vaccinated:2021-02-09
Onset:2021-02-09
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac arrest, Death, Resuscitation, Syncope, Ventricular fibrillation, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type': MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.


Changed on 5/7/2021

VAERS ID: 1026443 Before After
VAERS Form:2
Age:76.0
Sex:Female
Location:Mississippi
Vaccinated:2021-02-09
Onset:2021-02-09
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac arrest, Death, Resuscitation, Syncope, Ventricular fibrillation, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type': MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.


Changed on 5/14/2021

VAERS ID: 1026443 Before After
VAERS Form:2
Age:76.0
Sex:Female
Location:Mississippi
Vaccinated:2021-02-09
Onset:2021-02-09
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac arrest, Death, Resuscitation, Syncope, Ventricular fibrillation, Pulseless electrical activity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type': MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1026443&WAYBACKHISTORY=ON


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