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This is VAERS ID 1036460

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036460
VAERS Form:2
Age:90.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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:
Current Illness: liver cancer
Preexisting Conditions: liver cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: death 2-5-21


Changed on 5/7/2021

VAERS ID: 1036460 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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:
Current Illness: liver cancer
Preexisting Conditions: liver cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: death 2-5-21


Changed on 5/14/2021

VAERS ID: 1036460 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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:
Current Illness: liver cancer
Preexisting Conditions: liver cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: death 2-5-21

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1036460&WAYBACKHISTORY=ON


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