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This is VAERS ID 1080404

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1080404
VAERS Form:2
Age:88.0
Sex:Male
Location:New York
Vaccinated:2021-01-25
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Chills, Confusional state, Dyspnoea, Fatigue, Lethargy, Pneumonia, Decreased appetite, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Pneumonia, Jan. 2, 2021
Preexisting Conditions: hypertension, congestive heart failure
Allergies: Unknown
Diagnostic Lab Data: Covid rapid test, others unknown
CDC 'Split Type':

Write-up: Severe fatigue, lethargy observed by family members on date of discharge from sub-acute nursing care to home 02/03/2021 and subsequently on 02/04/21 with complaint of shortness of breath. Continued lethargy and shortness of breath on 02/05/21, 02/06/21. Lethargy, shortness of breath and loss of appetite, chills, on 02/07/21. Less lethargic on 02/08/2021 but worsened shortness of breath and loss of appetite. Patient requested 911 call on afternoon of 02/09/2021 for shortness of breath. Rapid Covid screen at ER was positive and staff reported beginning treatment with dexamethasone and remdesivir. Hospital staff reported to family that patient had pneumonia, congestive heart failure, confusion on 02/10/2021. Nursing staff reported patient was getting antivirals and antibiotics. Patient was transported for care by pulmonary specialist at Hospital on 02/13/2021.


Changed on 5/7/2021

VAERS ID: 1080404 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:New York
Vaccinated:2021-01-25
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Chills, Confusional state, Dyspnoea, Fatigue, Lethargy, Pneumonia, Decreased appetite, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Pneumonia, Jan. 2, 2021
Preexisting Conditions: hypertension, congestive heart failure
Allergies: Unknown Unknown
Diagnostic Lab Data: Covid rapid test, others unknown
CDC 'Split Type':

Write-up: Severe fatigue, lethargy observed by family members on date of discharge from sub-acute nursing care to home 02/03/2021 and subsequently on 02/04/21 with complaint of shortness of breath. Continued lethargy and shortness of breath on 02/05/21, 02/06/21. Lethargy, shortness of breath and loss of appetite, chills, on 02/07/21. Less lethargic on 02/08/2021 but worsened shortness of breath and loss of appetite. Patient requested 911 call on afternoon of 02/09/2021 for shortness of breath. Rapid Covid screen at ER was positive and staff reported beginning treatment with dexamethasone and remdesivir. Hospital staff reported to family that patient had pneumonia, congestive heart failure, confusion on 02/10/2021. Nursing staff reported patient was getting antivirals and antibiotics. Patient was transported for care by pulmonary specialist at Hospital on 02/13/2021.


Changed on 5/14/2021

VAERS ID: 1080404 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:New York
Vaccinated:2021-01-25
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Chills, Confusional state, Dyspnoea, Fatigue, Lethargy, Pneumonia, Decreased appetite, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 6     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Pneumonia, Jan. 2, 2021
Preexisting Conditions: hypertension, congestive heart failure
Allergies: Unknown Unknown
Diagnostic Lab Data: Covid rapid test, others unknown
CDC 'Split Type':

Write-up: Severe fatigue, lethargy observed by family members on date of discharge from sub-acute nursing care to home 02/03/2021 and subsequently on 02/04/21 with complaint of shortness of breath. Continued lethargy and shortness of breath on 02/05/21, 02/06/21. Lethargy, shortness of breath and loss of appetite, chills, on 02/07/21. Less lethargic on 02/08/2021 but worsened shortness of breath and loss of appetite. Patient requested 911 call on afternoon of 02/09/2021 for shortness of breath. Rapid Covid screen at ER was positive and staff reported beginning treatment with dexamethasone and remdesivir. Hospital staff reported to family that patient had pneumonia, congestive heart failure, confusion on 02/10/2021. Nursing staff reported patient was getting antivirals and antibiotics. Patient was transported for care by pulmonary specialist at Hospital on 02/13/2021.

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