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This is VAERS ID 1031593

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1031593
VAERS Form:2
Age:81.0
Sex:Male
Location:Georgia
Vaccinated:2021-02-11
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Hypersomnia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Calcitriol 0.25mcg, glyburide 2.5mg, atorvastatin 40mg, nitroglycerin 0.4mg, furosemide 40mg, isosorbide ER 60mg, warfarin 5mg, gabapentin 300mg, allopurinol 100mg
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On February 11, 2021 around 10:15 am, patient was given the Moderna brand COVID-19 vaccination. After his vaccination, he was instructed to wait around for 15 minutes after the administration of the vaccine. During this time, there were no reported issues with the patient. On February 15, 2021 around 9:15am, patient''s wife called the pharmacy and spoke with the pharmacist informing her that patient had passed away in his sleep on Saturday evening. Patient''s wife inquired about whether death may have been caused by an adverse reaction to the vaccine. During the call patient''s wife mentioned that patient slept a lot the day of the vaccine and the day after. patient''s wife mentioned that patient woke up Saturday to eat breakfast and lunch. She states that later that evening, she found patient asleep and cold which she then realized that he''d passed away.


Changed on 5/7/2021

VAERS ID: 1031593 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Georgia
Vaccinated:2021-02-11
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Hypersomnia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Calcitriol 0.25mcg, glyburide 2.5mg, atorvastatin 40mg, nitroglycerin 0.4mg, furosemide 40mg, isosorbide ER 60mg, warfarin 5mg, gabapentin 300mg, allopurinol 100mg
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On February 11, 2021 around 10:15 am, patient was given the Moderna brand COVID-19 vaccination. After his vaccination, he was instructed to wait around for 15 minutes after the administration of the vaccine. During this time, there were no reported issues with the patient. On February 15, 2021 around 9:15am, patient''s wife called the pharmacy and spoke with the pharmacist informing her that patient had passed away in his sleep on Saturday evening. Patient''s wife inquired about whether death may have been caused by an adverse reaction to the vaccine. During the call patient''s wife mentioned that patient slept a lot the day of the vaccine and the day after. patient''s wife mentioned that patient woke up Saturday to eat breakfast and lunch. She states that later that evening, she found patient asleep and cold which she then realized that he''d passed away.


Changed on 5/14/2021

VAERS ID: 1031593 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Georgia
Vaccinated:2021-02-11
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Hypersomnia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Calcitriol 0.25mcg, glyburide 2.5mg, atorvastatin 40mg, nitroglycerin 0.4mg, furosemide 40mg, isosorbide ER 60mg, warfarin 5mg, gabapentin 300mg, allopurinol 100mg
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On February 11, 2021 around 10:15 am, patient was given the Moderna brand COVID-19 vaccination. After his vaccination, he was instructed to wait around for 15 minutes after the administration of the vaccine. During this time, there were no reported issues with the patient. On February 15, 2021 around 9:15am, patient''s wife called the pharmacy and spoke with the pharmacist informing her that patient had passed away in his sleep on Saturday evening. Patient''s wife inquired about whether death may have been caused by an adverse reaction to the vaccine. During the call patient''s wife mentioned that patient slept a lot the day of the vaccine and the day after. patient''s wife mentioned that patient woke up Saturday to eat breakfast and lunch. She states that later that evening, she found patient asleep and cold which she then realized that he''d passed away.

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