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This is VAERS ID 1058171

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1058171
VAERS Form:2
Age:89.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
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: Pacemaker, high blood pressure, kidney disease, dementia
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/7/2021

VAERS ID: 1058171 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
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: Pacemaker, high blood pressure, kidney disease, dementia
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/14/2021

VAERS ID: 1058171 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
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: Pacemaker, high blood pressure, kidney disease, dementia
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1058171&WAYBACKHISTORY=ON

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