National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1036480

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036480
VAERS Form:2
Age:
Sex:Male
Location:Illinois
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Cough, Death, Endotracheal intubation, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: amlodipine, aspirin, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21


Changed on 5/7/2021

VAERS ID: 1036480 Before After
VAERS Form:2
Age:
Sex:Male
Location:Illinois
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Cough, Death, Endotracheal intubation, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: amlodipine, aspirin, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21


Changed on 5/14/2021

VAERS ID: 1036480 Before After
VAERS Form:2
Age:
Sex:Male
Location:Illinois
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Cough, Death, Endotracheal intubation, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: amlodipine, aspirin, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1036480&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166