National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1075363

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1075363
VAERS Form:2
Age:69.0
Sex:Male
Location:California
Vaccinated:2021-02-25
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Public      Purchased by: ??
Symptoms: Death, Pulmonary embolism, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-27
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: TBD
Current Illness: NA
Preexisting Conditions: DM Type II
Allergies: TBD
Diagnostic Lab Data: Coroner report/autopsy
CDC 'Split Type':

Write-up: Death due to Moderna 2nd dose, pulmonary thromboembolism


Changed on 5/7/2021

VAERS ID: 1075363 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:California
Vaccinated:2021-02-25
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Public      Purchased by: ??
Symptoms: Death, Pulmonary embolism, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-27
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: TBD
Current Illness: NA
Preexisting Conditions: DM Type II
Allergies: TBD TBD
Diagnostic Lab Data: Coroner report/autopsy
CDC 'Split Type':

Write-up: Death due to Moderna 2nd dose, pulmonary thromboembolism


Changed on 5/14/2021

VAERS ID: 1075363 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:California
Vaccinated:2021-02-25
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Public      Purchased by: ??
Symptoms: Death, Pulmonary embolism, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-27
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: TBD
Current Illness: NA
Preexisting Conditions: DM Type II
Allergies: TBD TBD
Diagnostic Lab Data: Coroner report/autopsy
CDC 'Split Type':

Write-up: Death due to Moderna 2nd dose, pulmonary thromboembolism

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1075363&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166