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This is VAERS ID 104095

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 104095
VAERS Form:
Age:68.1
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 / MEDEVA PHARMS LI E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: INFARCT MYOCARD

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 12/8/2009

VAERS ID: 104095 Before After
VAERS Form:
Age:68.1
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-04 1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUVIRIN 1997-1998 INFLUENZA (SEASONAL) (FLUVIRIN 97-98) / MEDEVA PHARMS LI MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction, INFARCT MYOCARD

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 8/31/2010

VAERS ID: 104095 Before After
VAERS Form:
Age:68.1
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN 97-98) INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 7/7/2013

VAERS ID: 104095 Before After
VAERS Form:
Age:68.1
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 2/14/2017

VAERS ID: 104095 Before After
VAERS Form:
Age:68.1 68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 5/14/2017

VAERS ID: 104095 Before After
VAERS Form:
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 9/14/2017

VAERS ID: 104095 Before After
VAERS Form:(blank) 1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 0 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 2/14/2018

VAERS ID: 104095 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 6/14/2018

VAERS ID: 104095 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 8/14/2018

VAERS ID: 104095 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 9/14/2018

VAERS ID: 104095 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;


Changed on 10/14/2018

VAERS ID: 104095 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Mississippi
Vaccinated:1997-10-15
Onset:1997-10-15
Submitted:1997-10-16
Entered:1997-11-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E3287GB / 1 RA / IM

Administered by: Public      Purchased by: Unknown
Symptoms: Myocardial infarction

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-10-15
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: ~ ()~~~In patient
Other Medications: GLynase, Corzide
Current Illness:
Preexisting Conditions: HTN, diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': MS97040

Write-up: pt recv vax 15OCT97 830 to 930AM & same day died;corner states COD massive MI;

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