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This is VAERS ID 1083728

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1083728
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal discomfort, Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Medical History/Concurrent Conditions: Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Dead on the bed with his legs dangling off one side of the bed; Complained about an upset stomach; A spontaneous report was received from a nurse concerning a 70-year-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273). The patient''s medical history included hypertension and diabetes. No concomitant medications were provided. On 20 Feb 2021, Saturday, the patient received their dose of mRNA-1273 (Batch Number: Unknown) for prophylaxis of COVID-19 infection. On 21 Feb 2021, Sunday 9:36 AM the patient''s experienced an upset stomach and attributed it to dinner last night and later on 22 Feb 2021, Monday he was found dead on the bed with his legs dangling off one side of the bed. The cause of death was unknown. Treatment information for event upset stomach included half a spoon of an Indian thing. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event upset stomach was fatal and patient died on 21 Feb 2021.; Reporter''s Comments: This is a 70-year-old, male patient, who received Moderna''s COVID-19 vaccine and history of risk factors for CAD such as hypertension and diabetes, was found dead 2 days after vaccination. Very limited information regarding this events has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1083728 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal discomfort, Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Medical History/Concurrent Conditions: Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Dead on the bed with his legs dangling off one side of the bed; Complained about an upset stomach; A spontaneous report was received from a nurse concerning a 70-year-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273). The patient''s medical history included hypertension and diabetes. No concomitant medications were provided. On 20 Feb 2021, Saturday, the patient received their dose of mRNA-1273 (Batch Number: Unknown) for prophylaxis of COVID-19 infection. On 21 Feb 2021, Sunday 9:36 AM the patient''s experienced an upset stomach and attributed it to dinner last night and later on 22 Feb 2021, Monday he was found dead on the bed with his legs dangling off one side of the bed. The cause of death was unknown. Treatment information for event upset stomach included half a spoon of an Indian thing. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event upset stomach was fatal and patient died on 21 Feb 2021.; Reporter''s Comments: This is a 70-year-old, male patient, who received Moderna''s COVID-19 vaccine and history of risk factors for CAD such as hypertension and diabetes, was found dead 2 days after vaccination. Very limited information regarding this events has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1083728 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:California
Vaccinated:2021-02-20
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal discomfort, Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Medical History/Concurrent Conditions: Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Dead on the bed with his legs dangling off one side of the bed; Complained about an upset stomach; A spontaneous report was received from a nurse concerning a 70-year-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273). The patient''s medical history included hypertension and diabetes. No concomitant medications were provided. On 20 Feb 2021, Saturday, the patient received their dose of mRNA-1273 (Batch Number: Unknown) for prophylaxis of COVID-19 infection. On 21 Feb 2021, Sunday 9:36 AM the patient''s experienced an upset stomach and attributed it to dinner last night and later on 22 Feb 2021, Monday he was found dead on the bed with his legs dangling off one side of the bed. The cause of death was unknown. Treatment information for event upset stomach included half a spoon of an Indian thing. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event upset stomach was fatal and patient died on 21 Feb 2021.; Reporter''s Comments: This is a 70-year-old, male patient, who received Moderna''s COVID-19 vaccine and history of risk factors for CAD such as hypertension and diabetes, was found dead 2 days after vaccination. Very limited information regarding this events has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death

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