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This is VAERS ID 1027967

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1027967
VAERS Form:2
Age:76.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-15
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Coagulopathy, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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:
Current Illness: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy


Changed on 5/7/2021

VAERS ID: 1027967 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-15
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Coagulopathy, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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:
Current Illness: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy


Changed on 5/14/2021

VAERS ID: 1027967 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-15
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Coagulopathy, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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:
Current Illness: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy

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