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This is VAERS ID 1029068

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1029068
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-07
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

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: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known
Diagnostic Lab Data: Covid-19 positive
CDC 'Split Type':

Write-up: Patient was given vaccine the following day he died ,


Changed on 5/7/2021

VAERS ID: 1029068 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-07
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

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: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known known
Diagnostic Lab Data: Covid-19 positive
CDC 'Split Type':

Write-up: Patient was given vaccine the following day he died ,


Changed on 5/14/2021

VAERS ID: 1029068 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-07
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

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: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known known
Diagnostic Lab Data: Covid-19 positive
CDC 'Split Type':

Write-up: Patient was given vaccine the following day he died ,

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1029068&WAYBACKHISTORY=ON


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