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This is VAERS ID 1030025

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030025
VAERS Form:2
Age:
Sex:Male
Location:Oklahoma
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient was died. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, the patient received his first dose of mRNA-1273 (Lot number unknown) for prophylaxis of COVID-19 infection. On an unknown date, the patient was died. Treatment of this event was not provided. The patient was died. The cause of death was not provided. Autopsy details were not provided.; Reporter''s Comments: This case concerns a male patient (unknown age), who experienced event of death (cause unknown). The event occurred on an unknown date after the first and last dose of mRNA-1273 vaccine administration. Autopsy and cause of death were not reported. Based on the current available limited information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded and the events are assessed as possibly related.; Reported Cause(s) of Death: Death


Changed on 5/7/2021

VAERS ID: 1030025 Before After
VAERS Form:2
Age:
Sex:Male
Location:Oklahoma
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient was died. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, the patient received his first dose of mRNA-1273 (Lot number unknown) for prophylaxis of COVID-19 infection. On an unknown date, the patient was died. Treatment of this event was not provided. The patient was died. The cause of death was not provided. Autopsy details were not provided.; Reporter''s Comments: This case concerns a male patient (unknown age), who experienced event of death (cause unknown). The event occurred on an unknown date after the first and last dose of mRNA-1273 vaccine administration. Autopsy and cause of death were not reported. Based on the current available limited information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded and the events are assessed as possibly related.; Reported Cause(s) of Death: Death


Changed on 5/14/2021

VAERS ID: 1030025 Before After
VAERS Form:2
Age:
Sex:Male
Location:Oklahoma
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient was died. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, the patient received his first dose of mRNA-1273 (Lot number unknown) for prophylaxis of COVID-19 infection. On an unknown date, the patient was died. Treatment of this event was not provided. The patient was died. The cause of death was not provided. Autopsy details were not provided.; Reporter''s Comments: This case concerns a male patient (unknown age), who experienced event of death (cause unknown). The event occurred on an unknown date after the first and last dose of mRNA-1273 vaccine administration. Autopsy and cause of death were not reported. Based on the current available limited information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded and the events are assessed as possibly related.; Reported Cause(s) of Death: Death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1030025&WAYBACKHISTORY=ON


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