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This is VAERS ID 1054699

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1054699
VAERS Form:2
Age:82.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep


Changed on 5/7/2021

VAERS ID: 1054699 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep


Changed on 5/14/2021

VAERS ID: 1054699 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1054699&WAYBACKHISTORY=ON

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