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This is VAERS ID 1026671

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1026671
VAERS Form:2
Age:95.0
Sex:Female
Location:Tennessee
Vaccinated:2021-01-06
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC 'Split Type':

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.


Changed on 3/26/2021

VAERS ID: 1026671 Before After
VAERS Form:2
Age:95.0
Sex:Female
Location:Tennessee
Vaccinated:2021-01-06
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC 'Split Type':

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.


Changed on 5/7/2021

VAERS ID: 1026671 Before After
VAERS Form:2
Age:95.0
Sex:Female
Location:Tennessee
Vaccinated:2021-01-06
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC 'Split Type':

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.


Changed on 5/14/2021

VAERS ID: 1026671 Before After
VAERS Form:2
Age:95.0
Sex:Female
Location:Tennessee
Vaccinated:2021-01-06
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC 'Split Type':

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1026671&WAYBACKHISTORY=ON


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