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This is VAERS ID 1075608

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1075608
VAERS Form:2
Age:72.0
Sex:Female
Location:New Jersey
Vaccinated:2021-03-03
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
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: unknown
Current Illness: Hx of Ca of the breast, last chemotherapy treatment 2/15/21
Preexisting Conditions: Breast cancer
Allergies: Denies
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Patient waited 15 mins after covid vaccination on Wednesday 3/3, cleared by EMT to leave. I was notified by nurse at the senior building where patient resides that she had expired Thursday evening at home. Paramedics were called. No other additional information.


Changed on 5/7/2021

VAERS ID: 1075608 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:New Jersey
Vaccinated:2021-03-03
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
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: unknown
Current Illness: Hx of Ca of the breast, last chemotherapy treatment 2/15/21
Preexisting Conditions: Breast cancer
Allergies: Denies Denies
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Patient waited 15 mins after covid vaccination on Wednesday 3/3, cleared by EMT to leave. I was notified by nurse at the senior building where patient resides that she had expired Thursday evening at home. Paramedics were called. No other additional information.


Changed on 5/14/2021

VAERS ID: 1075608 Before After
VAERS Form:2
Age:72.0
Sex:Female
Location:New Jersey
Vaccinated:2021-03-03
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
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: unknown
Current Illness: Hx of Ca of the breast, last chemotherapy treatment 2/15/21
Preexisting Conditions: Breast cancer
Allergies: Denies Denies
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Patient waited 15 mins after covid vaccination on Wednesday 3/3, cleared by EMT to leave. I was notified by nurse at the senior building where patient resides that she had expired Thursday evening at home. Paramedics were called. No other additional information.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1075608&WAYBACKHISTORY=ON


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