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This is VAERS ID 1074894

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1074894
VAERS Form:2
Age:94.0
Sex:Male
Location:New York
Vaccinated:2021-01-26
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate normal, Pneumonia, Influenza A virus test negative, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Eliquis, Metoprolol succinate, Upcal w/Vitamin D, senna, levothyroxine, vitamin D3
Current Illness: None
Preexisting Conditions: Cerebrovascular disease, vascular dementia, ASCVD, CAD, PVD, HTN, CHF, Afib, Hyperlipidemia, DMII, Hypothyroidism, OA, DJD, DDD, gout, CKD stage 3a, BPH, GERD, Vitamin D deficiency, osteopenia
Allergies: Bactrim DS, Zetia, Flomax, Crestor, Proscar
Diagnostic Lab Data: 2/10/21: BUN=58, Cr=1.7, EGFR=40, Na=154, Cl=120 2/11/21: COVID-19 swab negative 2/2/21: Influenza A&B negative
CDC 'Split Type':

Write-up: Patient became ill with pneumonia on 1/29/21 and then recurrent pneumonia on 2/10/21. Pt''s plan of care was subsequently changed to comfort-focused on 2/11/21 and patient was deceased that same day.


Changed on 5/7/2021

VAERS ID: 1074894 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:New York
Vaccinated:2021-01-26
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate normal, Pneumonia, Influenza A virus test negative, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Eliquis, Metoprolol succinate, Upcal w/Vitamin D, senna, levothyroxine, vitamin D3
Current Illness: None
Preexisting Conditions: Cerebrovascular disease, vascular dementia, ASCVD, CAD, PVD, HTN, CHF, Afib, Hyperlipidemia, DMII, Hypothyroidism, OA, DJD, DDD, gout, CKD stage 3a, BPH, GERD, Vitamin D deficiency, osteopenia
Allergies: Bactrim DS, Zetia, Flomax, Crestor, Proscar Proscar
Diagnostic Lab Data: 2/10/21: BUN=58, Cr=1.7, EGFR=40, Na=154, Cl=120 2/11/21: COVID-19 swab negative 2/2/21: Influenza A&B negative
CDC 'Split Type':

Write-up: Patient became ill with pneumonia on 1/29/21 and then recurrent pneumonia on 2/10/21. Pt''s plan of care was subsequently changed to comfort-focused on 2/11/21 and patient was deceased that same day.


Changed on 5/14/2021

VAERS ID: 1074894 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:New York
Vaccinated:2021-01-26
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate normal, Pneumonia, Influenza A virus test negative, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
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: Eliquis, Metoprolol succinate, Upcal w/Vitamin D, senna, levothyroxine, vitamin D3
Current Illness: None
Preexisting Conditions: Cerebrovascular disease, vascular dementia, ASCVD, CAD, PVD, HTN, CHF, Afib, Hyperlipidemia, DMII, Hypothyroidism, OA, DJD, DDD, gout, CKD stage 3a, BPH, GERD, Vitamin D deficiency, osteopenia
Allergies: Bactrim DS, Zetia, Flomax, Crestor, Proscar Proscar
Diagnostic Lab Data: 2/10/21: BUN=58, Cr=1.7, EGFR=40, Na=154, Cl=120 2/11/21: COVID-19 swab negative 2/2/21: Influenza A&B negative
CDC 'Split Type':

Write-up: Patient became ill with pneumonia on 1/29/21 and then recurrent pneumonia on 2/10/21. Pt''s plan of care was subsequently changed to comfort-focused on 2/11/21 and patient was deceased that same day.

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