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This is VAERS ID 1054694

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1054694
VAERS Form:2
Age:83.0
Sex:Male
Location:New Mexico
Vaccinated:2021-01-29
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness:
Preexisting Conditions: HTN, BPH, OSA, Obesity
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt received vaccine on 1/29/2021 and died on 2/13/2021. Wife called agency and noted the pt received his 1st dose of vaccine and was having "side effects and began declining". It is unknown what side effects he was having.


Changed on 5/7/2021

VAERS ID: 1054694 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:New Mexico
Vaccinated:2021-01-29
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness:
Preexisting Conditions: HTN, BPH, OSA, Obesity
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt received vaccine on 1/29/2021 and died on 2/13/2021. Wife called agency and noted the pt received his 1st dose of vaccine and was having "side effects and began declining". It is unknown what side effects he was having.


Changed on 5/14/2021

VAERS ID: 1054694 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:New Mexico
Vaccinated:2021-01-29
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness:
Preexisting Conditions: HTN, BPH, OSA, Obesity
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt received vaccine on 1/29/2021 and died on 2/13/2021. Wife called agency and noted the pt received his 1st dose of vaccine and was having "side effects and began declining". It is unknown what side effects he was having.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1054694&WAYBACKHISTORY=ON

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