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This is VAERS ID 1082759

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1082759
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/7/2021

VAERS ID: 1082759 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/14/2021

VAERS ID: 1082759 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1082759&WAYBACKHISTORY=ON

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