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This is VAERS ID 1030729

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030729
VAERS Form:2
Age:79.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-15
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: 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: clopidogrel, levothyroxine, glipizide
Current Illness: n/a
Preexisting Conditions: kidney
Allergies: n/a
Diagnostic Lab Data: na
CDC 'Split Type':

Write-up: deceased, 2/1/21


Changed on 5/7/2021

VAERS ID: 1030729 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-15
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: 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: clopidogrel, levothyroxine, glipizide
Current Illness: n/a
Preexisting Conditions: kidney
Allergies: n/a n/a
Diagnostic Lab Data: na
CDC 'Split Type':

Write-up: deceased, 2/1/21


Changed on 5/14/2021

VAERS ID: 1030729 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-15
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: 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: clopidogrel, levothyroxine, glipizide
Current Illness: n/a
Preexisting Conditions: kidney
Allergies: n/a n/a
Diagnostic Lab Data: na
CDC 'Split Type':

Write-up: deceased, 2/1/21

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