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This is VAERS ID 1061040

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1061040
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal pain upper, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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: Well controlled Insulin Diabetic meds
Current Illness: Insulin Dependant Diabetes
Preexisting Conditions: DM
Allergies: not known
Diagnostic Lab Data: not known
CDC 'Split Type':

Write-up: Text message from patient : 2.37 pm Saturday 02/20/2021 had the vaccine , waiting for 15 minutes & 2nd dose due 3/18/2021 Test message 9.44 am Sunday :feeling little sick with stomach ach No answer to phone calls on Cell/ Landline on Sunday No answer to phone call/ or text message No further communication.


Changed on 5/7/2021

VAERS ID: 1061040 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal pain upper, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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: Well controlled Insulin Diabetic meds
Current Illness: Insulin Dependant Diabetes
Preexisting Conditions: DM
Allergies: not known known
Diagnostic Lab Data: not known
CDC 'Split Type':

Write-up: Text message from patient : 2.37 pm Saturday 02/20/2021 had the vaccine , waiting for 15 minutes & 2nd dose due 3/18/2021 Test message 9.44 am Sunday :feeling little sick with stomach ach No answer to phone calls on Cell/ Landline on Sunday No answer to phone call/ or text message No further communication.


Changed on 5/14/2021

VAERS ID: 1061040 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal pain upper, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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: Well controlled Insulin Diabetic meds
Current Illness: Insulin Dependant Diabetes
Preexisting Conditions: DM
Allergies: not known known
Diagnostic Lab Data: not known
CDC 'Split Type':

Write-up: Text message from patient : 2.37 pm Saturday 02/20/2021 had the vaccine , waiting for 15 minutes & 2nd dose due 3/18/2021 Test message 9.44 am Sunday :feeling little sick with stomach ach No answer to phone calls on Cell/ Landline on Sunday No answer to phone call/ or text message No further communication.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1061040&WAYBACKHISTORY=ON

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