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This is VAERS ID 1035878

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1035878
VAERS Form:2
Age:88.0
Sex:Male
Location:Missouri
Vaccinated:2021-02-13
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
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: Aspirin, Atorvastatin
Current Illness: AIED; CHF; Type 2 DM; HTN; Chronic Renal Failure; Lung CA
Preexisting Conditions: See above
Allergies: None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Daughter called to report that the patient died on 02/15/2021. No report of symptoms from the vaccine on 02/13/2021


Changed on 5/7/2021

VAERS ID: 1035878 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Missouri
Vaccinated:2021-02-13
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
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: Aspirin, Atorvastatin
Current Illness: AIED; CHF; Type 2 DM; HTN; Chronic Renal Failure; Lung CA
Preexisting Conditions: See above
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Daughter called to report that the patient died on 02/15/2021. No report of symptoms from the vaccine on 02/13/2021


Changed on 5/14/2021

VAERS ID: 1035878 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Missouri
Vaccinated:2021-02-13
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
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: Aspirin, Atorvastatin
Current Illness: AIED; CHF; Type 2 DM; HTN; Chronic Renal Failure; Lung CA
Preexisting Conditions: See above
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Daughter called to report that the patient died on 02/15/2021. No report of symptoms from the vaccine on 02/13/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1035878&WAYBACKHISTORY=ON

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