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This is VAERS ID 1031993

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1031993
VAERS Form:2
Age:89.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Influenza like illness

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: Unkown
Current Illness:
Preexisting Conditions:
Allergies: KNDA or other allergies listed
Diagnostic Lab Data: When check on next morning by staff patient was deceased.
CDC 'Split Type':

Write-up: Patient reported mild flu like symptoms from vaccination later that evening. Next morning LTCF staff found pt deceased


Changed on 5/7/2021

VAERS ID: 1031993 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Influenza like illness

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: Unkown
Current Illness:
Preexisting Conditions:
Allergies: KNDA or other allergies listed listed
Diagnostic Lab Data: When check on next morning by staff patient was deceased.
CDC 'Split Type':

Write-up: Patient reported mild flu like symptoms from vaccination later that evening. Next morning LTCF staff found pt deceased


Changed on 5/14/2021

VAERS ID: 1031993 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Influenza like illness

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: Unkown
Current Illness:
Preexisting Conditions:
Allergies: KNDA or other allergies listed listed
Diagnostic Lab Data: When check on next morning by staff patient was deceased.
CDC 'Split Type':

Write-up: Patient reported mild flu like symptoms from vaccination later that evening. Next morning LTCF staff found pt deceased

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031993&WAYBACKHISTORY=ON


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