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This is VAERS ID 1038517

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1038517
VAERS Form:2
Age:68.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, SARS-CoV-2 test negative

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: COVID negative via rapid test
CDC 'Split Type':

Write-up: Pt. received vaccine on 2/3/2021. Coded at home on 2/17/2021.


Changed on 5/7/2021

VAERS ID: 1038517 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, SARS-CoV-2 test negative

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data: COVID negative via rapid test
CDC 'Split Type':

Write-up: Pt. received vaccine on 2/3/2021. Coded at home on 2/17/2021.


Changed on 5/14/2021

VAERS ID: 1038517 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, SARS-CoV-2 test negative

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data: COVID negative via rapid test
CDC 'Split Type':

Write-up: Pt. received vaccine on 2/3/2021. Coded at home on 2/17/2021.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1038517&WAYBACKHISTORY=ON


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