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This is VAERS ID 1081547

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1081547
VAERS Form:2
Age:84.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: LIQUID PROTEIN, PRILOSEC, LACTOBACILLUS, ELIQUIS
Current Illness: NONE
Preexisting Conditions: A-FIB, PERIPHERAL VASCULAR DISEASE, HERNIA REPAIR WITH BOWEL RESECTION JANUARY 2021
Allergies: NONE
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: NO IMMEDIATE ADVERSE EVENTS PRESENT FOLLOWING IMMUNIZATION. RESIDENT WAS ALERT, RESPONSIVE, TALKATIVE, WITHOUT COMPLAINTS, AND ENGAGING IN NORMAL ACTIVITIES AFTER IMMUNIZATION, AS WELL AS THE FOLLOWING DAY. HE WAS FOUND IN BED THE SECOND MORNING AFTER VACCINATION (AT 6:25AM) WITHOUT VITAL SIGNS AND HAD EXPIRED PEACEFULLY IN HIS SLEEP. HE WAS A DNR, NO LIFE SUSTAINING MEASURES WERE PERFORMED.


Changed on 5/7/2021

VAERS ID: 1081547 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: LIQUID PROTEIN, PRILOSEC, LACTOBACILLUS, ELIQUIS
Current Illness: NONE
Preexisting Conditions: A-FIB, PERIPHERAL VASCULAR DISEASE, HERNIA REPAIR WITH BOWEL RESECTION JANUARY 2021
Allergies: NONE NONE
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: NO IMMEDIATE ADVERSE EVENTS PRESENT FOLLOWING IMMUNIZATION. RESIDENT WAS ALERT, RESPONSIVE, TALKATIVE, WITHOUT COMPLAINTS, AND ENGAGING IN NORMAL ACTIVITIES AFTER IMMUNIZATION, AS WELL AS THE FOLLOWING DAY. HE WAS FOUND IN BED THE SECOND MORNING AFTER VACCINATION (AT 6:25AM) WITHOUT VITAL SIGNS AND HAD EXPIRED PEACEFULLY IN HIS SLEEP. HE WAS A DNR, NO LIFE SUSTAINING MEASURES WERE PERFORMED.


Changed on 5/14/2021

VAERS ID: 1081547 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: LIQUID PROTEIN, PRILOSEC, LACTOBACILLUS, ELIQUIS
Current Illness: NONE
Preexisting Conditions: A-FIB, PERIPHERAL VASCULAR DISEASE, HERNIA REPAIR WITH BOWEL RESECTION JANUARY 2021
Allergies: NONE NONE
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: NO IMMEDIATE ADVERSE EVENTS PRESENT FOLLOWING IMMUNIZATION. RESIDENT WAS ALERT, RESPONSIVE, TALKATIVE, WITHOUT COMPLAINTS, AND ENGAGING IN NORMAL ACTIVITIES AFTER IMMUNIZATION, AS WELL AS THE FOLLOWING DAY. HE WAS FOUND IN BED THE SECOND MORNING AFTER VACCINATION (AT 6:25AM) WITHOUT VITAL SIGNS AND HAD EXPIRED PEACEFULLY IN HIS SLEEP. HE WAS A DNR, NO LIFE SUSTAINING MEASURES WERE PERFORMED.

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