VAERS ID: |
1041185 (history) |
Form: |
Version 2.0 |
Age: |
86.0 |
Sex: |
Male |
Location: |
Illinois |
Vaccinated: | 2021-01-04 |
Onset: | 2021-01-18 |
Days after vaccination: | 14 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-19 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / 1 |
AR / IM |
Administered by: Other Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-18
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Levadopa; colace; lorazepam and morphine Current Illness: COVID + 12/10/2020 recovered. Placed on Hospice care 10/2020 Preexisting Conditions: Dementia; HTN; Parkinson''s; Bladder Cancer Allergies: No Known Allergies Diagnostic Lab Data: Unknown CDC Split Type:
Write-up: Death within 30 days |