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This is VAERS ID 1030712

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030712
VAERS Form:2
Age:74.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-09
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chills, Death, Depressed level of consciousness, Fatigue, Loss of consciousness, Pyrexia, Respiratory rate increased, Decreased appetite, Food refusal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination


Changed on 5/7/2021

VAERS ID: 1030712 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-09
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chills, Death, Depressed level of consciousness, Fatigue, Loss of consciousness, Pyrexia, Respiratory rate increased, Decreased appetite, Food refusal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination


Changed on 5/14/2021

VAERS ID: 1030712 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-09
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Chills, Death, Depressed level of consciousness, Fatigue, Loss of consciousness, Pyrexia, Respiratory rate increased, Decreased appetite, Food refusal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination

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