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This is VAERS ID 1048882

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1048882
VAERS Form:2
Age:71.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-02-01
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Pulmonary embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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:
Current Illness:
Preexisting Conditions: diabetes
Allergies: Augmentin (hives)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered 2/1/2021 at approximately 9am. Due to self reporting of allergic reaction (hives) to Augmentin, patient was monitored on site for 30 minutes. After the monitoring period, she was cleared to go with no issues reported at the time. We were later informed that the patient passed away from a pulmonary embolism on 2/12/2021.


Changed on 5/7/2021

VAERS ID: 1048882 Before After
VAERS Form:2
Age:71.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-02-01
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Pulmonary embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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:
Current Illness:
Preexisting Conditions: diabetes
Allergies: Augmentin (hives) (hives)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered 2/1/2021 at approximately 9am. Due to self reporting of allergic reaction (hives) to Augmentin, patient was monitored on site for 30 minutes. After the monitoring period, she was cleared to go with no issues reported at the time. We were later informed that the patient passed away from a pulmonary embolism on 2/12/2021.


Changed on 5/14/2021

VAERS ID: 1048882 Before After
VAERS Form:2
Age:71.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-02-01
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Pulmonary embolism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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:
Current Illness:
Preexisting Conditions: diabetes
Allergies: Augmentin (hives) (hives)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered 2/1/2021 at approximately 9am. Due to self reporting of allergic reaction (hives) to Augmentin, patient was monitored on site for 30 minutes. After the monitoring period, she was cleared to go with no issues reported at the time. We were later informed that the patient passed away from a pulmonary embolism on 2/12/2021.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1048882&WAYBACKHISTORY=ON

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