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This is VAERS ID 1077079

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1077079
VAERS Form:2
Age:77.0
Sex:Female
Location:California
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Aspirin, Tylenol, Sennakot, Amlodipine
Current Illness: Coccyx wound (hospice care)
Preexisting Conditions: Diabetes Type 2
Allergies: Iodine (Skin Reaction)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and oriented with no signs or symptoms of sickness prior to immunization for 2nd dose of Pfizer COVID19 vaccine. Temperature 98.7. Patient under hospice care and DNR status for wound care (coccyx). Patient has no recollection of first dose, but no adverse reactions to first dose per her caregivers. Patient did not appear to have any adverse reactions to the vaccine after the 15 minute observation period. About 1 hr after vaccine administration, patient was reported deceased. No signs of swelling or allergic reaction at site of injection.


Changed on 5/7/2021

VAERS ID: 1077079 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:California
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Aspirin, Tylenol, Sennakot, Amlodipine
Current Illness: Coccyx wound (hospice care)
Preexisting Conditions: Diabetes Type 2
Allergies: Iodine (Skin Reaction) Reaction)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and oriented with no signs or symptoms of sickness prior to immunization for 2nd dose of Pfizer COVID19 vaccine. Temperature 98.7. Patient under hospice care and DNR status for wound care (coccyx). Patient has no recollection of first dose, but no adverse reactions to first dose per her caregivers. Patient did not appear to have any adverse reactions to the vaccine after the 15 minute observation period. About 1 hr after vaccine administration, patient was reported deceased. No signs of swelling or allergic reaction at site of injection.


Changed on 5/14/2021

VAERS ID: 1077079 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:California
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Aspirin, Tylenol, Sennakot, Amlodipine
Current Illness: Coccyx wound (hospice care)
Preexisting Conditions: Diabetes Type 2
Allergies: Iodine (Skin Reaction) Reaction)
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and oriented with no signs or symptoms of sickness prior to immunization for 2nd dose of Pfizer COVID19 vaccine. Temperature 98.7. Patient under hospice care and DNR status for wound care (coccyx). Patient has no recollection of first dose, but no adverse reactions to first dose per her caregivers. Patient did not appear to have any adverse reactions to the vaccine after the 15 minute observation period. About 1 hr after vaccine administration, patient was reported deceased. No signs of swelling or allergic reaction at site of injection.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1077079&WAYBACKHISTORY=ON


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