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This is VAERS ID 1036519

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036519
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Dyspnoea, Loss of consciousness, Nausea, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Albuterol-ipratropium, warfarin, hydrochlorothiazide-triamterene, budesonide-glycopyrroltate-formoterol, atorvastatin.
Current Illness:
Preexisting Conditions: Severe COPD, cor pulmonale, history of pulmonary embolism, chronic hypoxemic respiratory failure.
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Received first SARS-CoV2 vaccination yesterday at local store Experienced new symptoms of chills, nausea as well as worsening from baseline dyspnea at night. Wife states he had rough morning breathing and had sudden loss of consciousness and unresponsiveness and failed to respond to bystander CPR. He expired at his home.


Changed on 5/7/2021

VAERS ID: 1036519 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Dyspnoea, Loss of consciousness, Nausea, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Albuterol-ipratropium, warfarin, hydrochlorothiazide-triamterene, budesonide-glycopyrroltate-formoterol, atorvastatin.
Current Illness:
Preexisting Conditions: Severe COPD, cor pulmonale, history of pulmonary embolism, chronic hypoxemic respiratory failure.
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Received first SARS-CoV2 vaccination yesterday at local store Experienced new symptoms of chills, nausea as well as worsening from baseline dyspnea at night. Wife states he had rough morning breathing and had sudden loss of consciousness and unresponsiveness and failed to respond to bystander CPR. He expired at his home.


Changed on 5/14/2021

VAERS ID: 1036519 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Dyspnoea, Loss of consciousness, Nausea, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Albuterol-ipratropium, warfarin, hydrochlorothiazide-triamterene, budesonide-glycopyrroltate-formoterol, atorvastatin.
Current Illness:
Preexisting Conditions: Severe COPD, cor pulmonale, history of pulmonary embolism, chronic hypoxemic respiratory failure.
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Received first SARS-CoV2 vaccination yesterday at local store Experienced new symptoms of chills, nausea as well as worsening from baseline dyspnea at night. Wife states he had rough morning breathing and had sudden loss of consciousness and unresponsiveness and failed to respond to bystander CPR. He expired at his home.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1036519&WAYBACKHISTORY=ON

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