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This is VAERS ID 1053694

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1053694
VAERS Form:2
Age:62.0
Sex:Male
Location:Texas
Vaccinated:2021-02-08
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death on 2/17/2021


Changed on 5/7/2021

VAERS ID: 1053694 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Texas
Vaccinated:2021-02-08
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death on 2/17/2021


Changed on 5/14/2021

VAERS ID: 1053694 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Texas
Vaccinated:2021-02-08
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death on 2/17/2021

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