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This is VAERS ID 1057828

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1057828
VAERS Form:2
Age:66.0
Sex:Male
Location:North Carolina
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin 1000mg twice daily, Lisinopril 10mg once daily, aspirin 81mg once daily, amlodipine 10mg daily
Current Illness:
Preexisting Conditions: hypertension, type 2 diabetes, prostate cancer, melanoma, lumbar spondylosis, renal stones, GERD
Allergies: empagliflozin 10mg caused dizziness
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient unexpectedly died on 2/17 after 14 days of receiving first dose of COVID-19 vaccine. EMS presumed it could be from possible myocardial infarction.


Changed on 5/7/2021

VAERS ID: 1057828 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:North Carolina
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin 1000mg twice daily, Lisinopril 10mg once daily, aspirin 81mg once daily, amlodipine 10mg daily
Current Illness:
Preexisting Conditions: hypertension, type 2 diabetes, prostate cancer, melanoma, lumbar spondylosis, renal stones, GERD
Allergies: empagliflozin 10mg caused dizziness dizziness
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient unexpectedly died on 2/17 after 14 days of receiving first dose of COVID-19 vaccine. EMS presumed it could be from possible myocardial infarction.


Changed on 5/14/2021

VAERS ID: 1057828 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:North Carolina
Vaccinated:2021-02-03
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin 1000mg twice daily, Lisinopril 10mg once daily, aspirin 81mg once daily, amlodipine 10mg daily
Current Illness:
Preexisting Conditions: hypertension, type 2 diabetes, prostate cancer, melanoma, lumbar spondylosis, renal stones, GERD
Allergies: empagliflozin 10mg caused dizziness dizziness
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient unexpectedly died on 2/17 after 14 days of receiving first dose of COVID-19 vaccine. EMS presumed it could be from possible myocardial infarction.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1057828&WAYBACKHISTORY=ON


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