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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1026841



Case Details

VAERS ID: 1026841 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness:
Preexisting Conditions: Dementia, Hyperlipidemia, Hypertension, Osteoarthritis, Cerebral Infarction, COPD
Allergies: Aloe, Tetracycline
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident passed away this morning. No signs or symptoms prior to his death of an issue with the vaccine. He was an end stage dementia resident at the nursing home.


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