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This is VAERS ID 1029554

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1029554
VAERS Form:2
Age:66.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-17
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.


Changed on 5/7/2021

VAERS ID: 1029554 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-17
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.


Changed on 5/14/2021

VAERS ID: 1029554 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-17
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-01
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1029554&WAYBACKHISTORY=ON

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