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This is VAERS ID 1055290

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1055290
VAERS Form:2
Age:94.0
Sex:Female
Location:Michigan
Vaccinated:2021-02-08
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M208 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
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: not known at this time. I can research if needed
Current Illness: unknown
Preexisting Conditions: elderly
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death occurred 02/14/2021


Changed on 5/7/2021

VAERS ID: 1055290 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Michigan
Vaccinated:2021-02-08
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M208 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
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: not known at this time. I can research if needed
Current Illness: unknown
Preexisting Conditions: elderly
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death occurred 02/14/2021


Changed on 5/14/2021

VAERS ID: 1055290 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Michigan
Vaccinated:2021-02-08
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M208 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
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: not known at this time. I can research if needed
Current Illness: unknown
Preexisting Conditions: elderly
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death occurred 02/14/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1055290&WAYBACKHISTORY=ON


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