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This is VAERS ID 1054192

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1054192
VAERS Form:2
Age:71.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-16
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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: Unk
Current Illness: None listed
Preexisting Conditions: None listed
Allergies: NKA
Diagnostic Lab Data: Unk
CDC 'Split Type':

Write-up: Pt''s wife reports death 2/23/2021


Changed on 5/7/2021

VAERS ID: 1054192 Before After
VAERS Form:2
Age:71.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-16
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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: Unk
Current Illness: None listed
Preexisting Conditions: None listed
Allergies: NKA NKA
Diagnostic Lab Data: Unk
CDC 'Split Type':

Write-up: Pt''s wife reports death 2/23/2021


Changed on 5/14/2021

VAERS ID: 1054192 Before After
VAERS Form:2
Age:71.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-16
Onset:2021-02-23
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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: Unk
Current Illness: None listed
Preexisting Conditions: None listed
Allergies: NKA NKA
Diagnostic Lab Data: Unk
CDC 'Split Type':

Write-up: Pt''s wife reports death 2/23/2021

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1054192&WAYBACKHISTORY=ON

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