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This is VAERS ID 1037124

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1037124
VAERS Form:2
Age:53.0
Sex:Male
Location:New Jersey
Vaccinated:2021-02-04
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-16
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: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.


Changed on 5/7/2021

VAERS ID: 1037124 Before After
VAERS Form:2
Age:53.0
Sex:Male
Location:New Jersey
Vaccinated:2021-02-04
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-16
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: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.


Changed on 5/14/2021

VAERS ID: 1037124 Before After
VAERS Form:2
Age:53.0
Sex:Male
Location:New Jersey
Vaccinated:2021-02-04
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-16
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: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1037124&WAYBACKHISTORY=ON


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