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This is VAERS ID 1035552

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1035552
VAERS Form:2
Age:
Sex:Female
Location:Unknown
Vaccinated:2020-12-29
Onset:2020-12-29
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Body temperature, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: GABAPENTIN; MEMANTINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; Aphasia; Asthenia; Dementia; Iron deficiency; Major depressive disorder; Osteoporosis; Penicillin allergy; Polyneuropathy; Type II diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: Test Result:98 Fahrenheit
CDC 'Split Type': USPFIZER INC2021146318

Write-up: approxmately 1:30 Pm the resident passed away; This is a spontaneous report from a Pfizer sponsored program. A non-contactable consumer reported that a female patient of an unspecified age (reported as 85 without unit) received the 1st dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EL0140), intramuscular at left arm on 29Dec2020 11:29 at single dose for COVID-19 immunization. Medical history included dementia, aphasia, type 2 diabetes mellitus (DM), iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, Major depressive disorder (MDD). Concomitant medication included gabapentin, memantine. The patient had allergies to codiene, phenobarbital, penicillin. The vaccine was administrated with no immediate adverse reaction at 11:29. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 13:30 on 29Dec2020, the resident passed away. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected. ; Reported Cause(s) of Death: approxmately 1:30 Pm the resident passed away


Changed on 5/7/2021

VAERS ID: 1035552 Before After
VAERS Form:2
Age:
Sex:Female
Location:Unknown
Vaccinated:2020-12-29
Onset:2020-12-29
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Body temperature, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: GABAPENTIN; MEMANTINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; Aphasia; Asthenia; Dementia; Iron deficiency; Major depressive disorder; Osteoporosis; Penicillin allergy; Polyneuropathy; Type II diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: Test Result:98 Fahrenheit
CDC 'Split Type': USPFIZER INC2021146318

Write-up: approxmately 1:30 Pm the resident passed away; This is a spontaneous report from a Pfizer sponsored program. A non-contactable consumer reported that a female patient of an unspecified age (reported as 85 without unit) received the 1st dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EL0140), intramuscular at left arm on 29Dec2020 11:29 at single dose for COVID-19 immunization. Medical history included dementia, aphasia, type 2 diabetes mellitus (DM), iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, Major depressive disorder (MDD). Concomitant medication included gabapentin, memantine. The patient had allergies to codiene, phenobarbital, penicillin. The vaccine was administrated with no immediate adverse reaction at 11:29. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 13:30 on 29Dec2020, the resident passed away. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected. ; Reported Cause(s) of Death: approxmately 1:30 Pm the resident passed away


Changed on 5/14/2021

VAERS ID: 1035552 Before After
VAERS Form:2
Age:
Sex:Female
Location:Unknown
Vaccinated:2020-12-29
Onset:2020-12-29
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Body temperature, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: GABAPENTIN; MEMANTINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; Aphasia; Asthenia; Dementia; Iron deficiency; Major depressive disorder; Osteoporosis; Penicillin allergy; Polyneuropathy; Type II diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: Test Result:98 Fahrenheit
CDC 'Split Type': USPFIZER INC2021146318

Write-up: approxmately 1:30 Pm the resident passed away; This is a spontaneous report from a Pfizer sponsored program. A non-contactable consumer reported that a female patient of an unspecified age (reported as 85 without unit) received the 1st dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EL0140), intramuscular at left arm on 29Dec2020 11:29 at single dose for COVID-19 immunization. Medical history included dementia, aphasia, type 2 diabetes mellitus (DM), iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, Major depressive disorder (MDD). Concomitant medication included gabapentin, memantine. The patient had allergies to codiene, phenobarbital, penicillin. The vaccine was administrated with no immediate adverse reaction at 11:29. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 13:30 on 29Dec2020, the resident passed away. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected. ; Reported Cause(s) of Death: approxmately 1:30 Pm the resident passed away

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