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This is VAERS ID 1049963

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1049963
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-01-12
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Myocardial infarction, Pulse absent, Respiratory arrest, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.


Changed on 5/7/2021

VAERS ID: 1049963 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-01-12
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Myocardial infarction, Pulse absent, Respiratory arrest, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.


Changed on 5/14/2021

VAERS ID: 1049963 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-01-12
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Myocardial infarction, Pulse absent, Respiratory arrest, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1049963&WAYBACKHISTORY=ON

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