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This is VAERS ID 1059825

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1059825
VAERS Form:2
Age:90.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-24
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016MZOA / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Lethargy, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Donepezil 10mg daily Vitamin D3 5000 IU daily Eliquis 2.5mg twice daily Vitamin B12 1000mcg daily Enalapril 10mg daily Memantine HCL 10mg twice daily Claritin 10mg dai
Current Illness: none while at community- new move in.
Preexisting Conditions: Dementia HTN A-Fib Cancer
Allergies: NKA
Diagnostic Lab Data: 911 was called and resident went to hospital where treatment was provided there in ER dept. and I have been informed passed away.
CDC 'Split Type':

Write-up: 30 hours after the first Covid vaccination, the resident was lethargic, non responsive with shortness of breathe.


Changed on 5/7/2021

VAERS ID: 1059825 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-24
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016MZOA / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Lethargy, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Donepezil 10mg daily Vitamin D3 5000 IU daily Eliquis 2.5mg twice daily Vitamin B12 1000mcg daily Enalapril 10mg daily Memantine HCL 10mg twice daily Claritin 10mg dai
Current Illness: none while at community- new move in.
Preexisting Conditions: Dementia HTN A-Fib Cancer
Allergies: NKA NKA
Diagnostic Lab Data: 911 was called and resident went to hospital where treatment was provided there in ER dept. and I have been informed passed away.
CDC 'Split Type':

Write-up: 30 hours after the first Covid vaccination, the resident was lethargic, non responsive with shortness of breathe.


Changed on 5/14/2021

VAERS ID: 1059825 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Arizona
Vaccinated:2021-02-24
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016MZOA / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Lethargy, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-26
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Donepezil 10mg daily Vitamin D3 5000 IU daily Eliquis 2.5mg twice daily Vitamin B12 1000mcg daily Enalapril 10mg daily Memantine HCL 10mg twice daily Claritin 10mg dai
Current Illness: none while at community- new move in.
Preexisting Conditions: Dementia HTN A-Fib Cancer
Allergies: NKA NKA
Diagnostic Lab Data: 911 was called and resident went to hospital where treatment was provided there in ER dept. and I have been informed passed away.
CDC 'Split Type':

Write-up: 30 hours after the first Covid vaccination, the resident was lethargic, non responsive with shortness of breathe.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1059825&WAYBACKHISTORY=ON

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