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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1052070

Case Details

VAERS ID: 1052070 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: New Jersey  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Infrequent bowel movements, Nausea, Retching
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin EC tablet delayed release 81mg once a day, Lasix 20mg tablet once a day, Multivitamin once a day, Omeprazole tablet delayed release 20mg once a day, Probiotic Capsule 2 per day, Refresh PM eye ointment at bedtime, Tylenol Extra Str
Current Illness: No
Preexisting Conditions: Acute Diastolic (Congestive) Heart Failure, Bell''s Palsy, Essential Hypertension, Unspecified Atrial Fibrillation, Unspecified Macular Degeneration, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Gastro-esophageal Reflux Disease without Esophagitis, Dementia without Behavior Disturbances, Muscle Weakness, Overactive Bladder, H/O Ottis Media, Legal Blindness and Dysphagia
Allergies: No known drug or food allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 2/22/2021 10:09 pm resident reported 1 episode of being nauseous and having dry heaves, no temperature, MD notified and nurse was told to continue to monitor, no new orders, daughter made aware. Vital signs being done every 4 hours. 2/23/2021 3:04am resident complains of nausea, scant BM amount x 2, MD notified and no new orders, continue to monitor and encourage fluids, vital signs continue every 4 hours.

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