National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1077236

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1077236
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cough, Fall, Head injury, Resuscitation, Pulseless electrical activity, Agonal respiration

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: "sleeping pill"
Current Illness: cough after vaccine and weakness
Preexisting Conditions: none
Allergies: unknown
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Family states patient had been coughing and was weak after the vaccine. Patient walked to the bathroom and then fell striking her head found in PEA with agonal breathing. Despite aggressive CPR medications patient remained in asystole. Unknow if Moderna or Phifzer


Changed on 5/7/2021

VAERS ID: 1077236 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cough, Fall, Head injury, Resuscitation, Pulseless electrical activity, Agonal respiration

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: "sleeping pill"
Current Illness: cough after vaccine and weakness
Preexisting Conditions: none
Allergies: unknown unknown
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Family states patient had been coughing and was weak after the vaccine. Patient walked to the bathroom and then fell striking her head found in PEA with agonal breathing. Despite aggressive CPR medications patient remained in asystole. Unknow if Moderna or Phifzer


Changed on 5/14/2021

VAERS ID: 1077236 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Cough, Fall, Head injury, Resuscitation, Pulseless electrical activity, Agonal respiration

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: "sleeping pill"
Current Illness: cough after vaccine and weakness
Preexisting Conditions: none
Allergies: unknown unknown
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Family states patient had been coughing and was weak after the vaccine. Patient walked to the bathroom and then fell striking her head found in PEA with agonal breathing. Despite aggressive CPR medications patient remained in asystole. Unknow if Moderna or Phifzer

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1077236&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


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