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This is VAERS ID 1082161

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1082161
VAERS Form:2
Age:79.0
Sex:Male
Location:Nevada
Vaccinated:2021-03-03
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 RA / IM

Administered by: School      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Unknown
CDC 'Split Type':

Write-up: Cardiac Arrest/Death Date of death 03/03/2021 time 01:54 pm


Changed on 5/7/2021

VAERS ID: 1082161 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Nevada
Vaccinated:2021-03-03
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 RA / IM

Administered by: School      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Unknown
CDC 'Split Type':

Write-up: Cardiac Arrest/Death Date of death 03/03/2021 time 01:54 pm


Changed on 5/14/2021

VAERS ID: 1082161 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Nevada
Vaccinated:2021-03-03
Onset:2021-03-03
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 RA / IM

Administered by: School      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Unknown
CDC 'Split Type':

Write-up: Cardiac Arrest/Death Date of death 03/03/2021 time 01:54 pm

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1082161&WAYBACKHISTORY=ON

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