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This is VAERS ID 1026841

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1026841
VAERS Form:2
Age:80.0
Sex:Male
Location:Wyoming
Vaccinated:2021-02-11
Onset:2021-02-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: 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.


Changed on 5/7/2021

VAERS ID: 1026841 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Wyoming
Vaccinated:2021-02-11
Onset:2021-02-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: Tylenol
Current Illness:
Preexisting Conditions: Dementia, Hyperlipidemia, Hypertension, Osteoarthritis, Cerebral Infarction, COPD
Allergies: Aloe, Tetracycline 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.


Changed on 5/14/2021

VAERS ID: 1026841 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Wyoming
Vaccinated:2021-02-11
Onset:2021-02-12
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: Tylenol
Current Illness:
Preexisting Conditions: Dementia, Hyperlipidemia, Hypertension, Osteoarthritis, Cerebral Infarction, COPD
Allergies: Aloe, Tetracycline 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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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1026841&WAYBACKHISTORY=ON


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