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This is VAERS ID 1078002

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1078002
VAERS Form:2
Age:69.0
Sex:Male
Location:New York
Vaccinated:2021-02-22
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Cough, Death, Fatigue, Headache, Pain, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no
CDC 'Split Type':

Write-up: Fever, tiredness, headache, body ache and chills and cough. Patient passed away at homeThursday, March 5 around 5:00 a.m.


Changed on 5/7/2021

VAERS ID: 1078002 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:New York
Vaccinated:2021-02-22
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Cough, Death, Fatigue, Headache, Pain, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no
CDC 'Split Type':

Write-up: Fever, tiredness, headache, body ache and chills and cough. Patient passed away at homeThursday, March 5 around 5:00 a.m.


Changed on 5/14/2021

VAERS ID: 1078002 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:New York
Vaccinated:2021-02-22
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Cough, Death, Fatigue, Headache, Pain, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no
CDC 'Split Type':

Write-up: Fever, tiredness, headache, body ache and chills and cough. Patient passed away at homeThursday, March 5 around 5:00 a.m.


Changed on 9/10/2021

VAERS ID: 1078002 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:New York
Vaccinated:2021-02-22
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Cough, Death, Fatigue, Headache, Pain, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No Yes
   Date died:0000-00-00 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no
CDC 'Split Type':

Write-up: Fever, tiredness, headache, body ache and chills and cough. Patient passed away at homeThursday, March 5 around 5:00 a.m.

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