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This is VAERS ID 1069118

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1069118
VAERS Form:2
Age:72.0
Sex:Female
Location:Illinois
Vaccinated:2021-02-25
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dizziness, Nausea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.


Changed on 5/7/2021

VAERS ID: 1069118 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:Illinois
Vaccinated:2021-02-25
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dizziness, Nausea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax Zithromax
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.


Changed on 5/14/2021

VAERS ID: 1069118 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:Illinois
Vaccinated:2021-02-25
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Dizziness, Nausea, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax Zithromax
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.

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