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This is VAERS ID 1081009

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1081009
VAERS Form:2
Age:85.0
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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: combivent Respimat, Januvia 100mg,Metformin 500mg, vitamin C 100mg,Ferrous Sulfate 325mg,Famotidine 20mg,Sertraline 50mg,Carvedilol 12.5mg,Oyster shell calcium 500mg,Gabapentin 300mg,furosemide 20mg,EC Aspirin 325mg,atorvastatin 40mg,clopid
Current Illness: Cancer
Preexisting Conditions: diabetes, heart disease
Allergies: tramadol, morphine products
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: there were no signs of adverse reaction at the time of injections and she waited 15 minutes at the site to watch for side effects. and none were evident or reported. We were notified that she passed away on Saturday, March 6.


Changed on 5/7/2021

VAERS ID: 1081009 Before After
VAERS Form:2
Age:85.0
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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: combivent Respimat, Januvia 100mg,Metformin 500mg, vitamin C 100mg,Ferrous Sulfate 325mg,Famotidine 20mg,Sertraline 50mg,Carvedilol 12.5mg,Oyster shell calcium 500mg,Gabapentin 300mg,furosemide 20mg,EC Aspirin 325mg,atorvastatin 40mg,clopid
Current Illness: Cancer
Preexisting Conditions: diabetes, heart disease
Allergies: tramadol, morphine products products
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: there were no signs of adverse reaction at the time of injections and she waited 15 minutes at the site to watch for side effects. and none were evident or reported. We were notified that she passed away on Saturday, March 6.


Changed on 5/14/2021

VAERS ID: 1081009 Before After
VAERS Form:2
Age:85.0
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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: combivent Respimat, Januvia 100mg,Metformin 500mg, vitamin C 100mg,Ferrous Sulfate 325mg,Famotidine 20mg,Sertraline 50mg,Carvedilol 12.5mg,Oyster shell calcium 500mg,Gabapentin 300mg,furosemide 20mg,EC Aspirin 325mg,atorvastatin 40mg,clopid
Current Illness: Cancer
Preexisting Conditions: diabetes, heart disease
Allergies: tramadol, morphine products products
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: there were no signs of adverse reaction at the time of injections and she waited 15 minutes at the site to watch for side effects. and none were evident or reported. We were notified that she passed away on Saturday, March 6.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1081009&WAYBACKHISTORY=ON

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