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This is VAERS ID 1050158

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1050158
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-28
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Pulmonary congestion, Vomiting, Respiratory tract congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Tramadol HCI tab 50mg po Qday, Ambien titrate 5 mg PO QHS PRN, Promethazine DM Syrup 6.25-15mg/5ml give 5ml Q4hrs prn, Zofran 4mg 1 tab PO Q 4 hours PRN, Morphine sulfate 15mg give 0.5mg PO Q 4hours PRN , Bowel care
Current Illness: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Preexisting Conditions: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Allergies: No known allergies
Diagnostic Lab Data: Change of condition was acute and on same day passed away - 1-23-2021
CDC 'Split Type':

Write-up: Resident is a Hospice patient. On 1-23-2021 am shift resident was observed by nursing have chest congestion and had a emesis times 1 with SOB, Zofran 4 mg was given. HOB (02 sats 88%) was elevated resident on 02 via nasal canula with 02 sat now @ 90% . no respiratory distress noted. MD was called with response pending for orders. @ 1400 resident with no signs of life. vs 90%-24-97/71-97.6. Hospice on site and time of death 1436


Changed on 5/7/2021

VAERS ID: 1050158 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-28
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Pulmonary congestion, Vomiting, Respiratory tract congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Tramadol HCI tab 50mg po Qday, Ambien titrate 5 mg PO QHS PRN, Promethazine DM Syrup 6.25-15mg/5ml give 5ml Q4hrs prn, Zofran 4mg 1 tab PO Q 4 hours PRN, Morphine sulfate 15mg give 0.5mg PO Q 4hours PRN , Bowel care
Current Illness: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Preexisting Conditions: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Allergies: No known allergies allergies
Diagnostic Lab Data: Change of condition was acute and on same day passed away - 1-23-2021
CDC 'Split Type':

Write-up: Resident is a Hospice patient. On 1-23-2021 am shift resident was observed by nursing have chest congestion and had a emesis times 1 with SOB, Zofran 4 mg was given. HOB (02 sats 88%) was elevated resident on 02 via nasal canula with 02 sat now @ 90% . no respiratory distress noted. MD was called with response pending for orders. @ 1400 resident with no signs of life. vs 90%-24-97/71-97.6. Hospice on site and time of death 1436


Changed on 5/14/2021

VAERS ID: 1050158 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-28
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Pulmonary congestion, Vomiting, Respiratory tract congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Tramadol HCI tab 50mg po Qday, Ambien titrate 5 mg PO QHS PRN, Promethazine DM Syrup 6.25-15mg/5ml give 5ml Q4hrs prn, Zofran 4mg 1 tab PO Q 4 hours PRN, Morphine sulfate 15mg give 0.5mg PO Q 4hours PRN , Bowel care
Current Illness: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Preexisting Conditions: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Allergies: No known allergies allergies
Diagnostic Lab Data: Change of condition was acute and on same day passed away - 1-23-2021
CDC 'Split Type':

Write-up: Resident is a Hospice patient. On 1-23-2021 am shift resident was observed by nursing have chest congestion and had a emesis times 1 with SOB, Zofran 4 mg was given. HOB (02 sats 88%) was elevated resident on 02 via nasal canula with 02 sat now @ 90% . no respiratory distress noted. MD was called with response pending for orders. @ 1400 resident with no signs of life. vs 90%-24-97/71-97.6. Hospice on site and time of death 1436

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