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This is VAERS ID 1034146

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1034146
VAERS Form:2
Age:28.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-13
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 01620A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unevaluable event

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: N/A
Current Illness: WAS NOT REPORTED AT TIME OF VACCINATION
Preexisting Conditions:
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: ARRIVED AT EVENT, CONSENT FORM COMPLETED, DID NOT REPORT HE HAD BEEN ILL, DID NOT REPORT THAT HE TOOK ANY FEVER REDUCING MEDICATIONS


Changed on 5/7/2021

VAERS ID: 1034146 Before After
VAERS Form:2
Age:28.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-13
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 01620A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unevaluable event

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: N/A
Current Illness: WAS NOT REPORTED AT TIME OF VACCINATION
Preexisting Conditions:
Allergies: UNKNOWN UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: ARRIVED AT EVENT, CONSENT FORM COMPLETED, DID NOT REPORT HE HAD BEEN ILL, DID NOT REPORT THAT HE TOOK ANY FEVER REDUCING MEDICATIONS


Changed on 5/14/2021

VAERS ID: 1034146 Before After
VAERS Form:2
Age:28.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-13
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 01620A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unevaluable event

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: N/A
Current Illness: WAS NOT REPORTED AT TIME OF VACCINATION
Preexisting Conditions:
Allergies: UNKNOWN UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: ARRIVED AT EVENT, CONSENT FORM COMPLETED, DID NOT REPORT HE HAD BEEN ILL, DID NOT REPORT THAT HE TOOK ANY FEVER REDUCING MEDICATIONS

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1034146&WAYBACKHISTORY=ON

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