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This is VAERS ID 1030557

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030557
VAERS Form:2
Age:69.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-02-10
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Aortic aneurysm rupture, Death, Loss of consciousness, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan/HCTZ 100/25mg Alendronate Sodium 70mg
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: According to her husband, approximately 3 hours after vaccine, patients clasped and was instantly unconscious. She was pronounced dead upon arrival to hospital and physician told husband that she had suffered a burst abdominal aneurysm and passed immediately. Nothing was out of ordinary during vaccination and during 15 minute wait time after.


Changed on 5/7/2021

VAERS ID: 1030557 Before After
VAERS Form:2
Age:69.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-02-10
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Aortic aneurysm rupture, Death, Loss of consciousness, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan/HCTZ 100/25mg Alendronate Sodium 70mg
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: According to her husband, approximately 3 hours after vaccine, patients clasped and was instantly unconscious. She was pronounced dead upon arrival to hospital and physician told husband that she had suffered a burst abdominal aneurysm and passed immediately. Nothing was out of ordinary during vaccination and during 15 minute wait time after.


Changed on 5/14/2021

VAERS ID: 1030557 Before After
VAERS Form:2
Age:69.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-02-10
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Aortic aneurysm rupture, Death, Loss of consciousness, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan/HCTZ 100/25mg Alendronate Sodium 70mg
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: According to her husband, approximately 3 hours after vaccine, patients clasped and was instantly unconscious. She was pronounced dead upon arrival to hospital and physician told husband that she had suffered a burst abdominal aneurysm and passed immediately. Nothing was out of ordinary during vaccination and during 15 minute wait time after.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1030557&WAYBACKHISTORY=ON


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