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This is VAERS ID 1084419

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1084419
VAERS Form:2
Age:61.0
Sex:Male
Location:Maine
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose increased, Cardiac arrest, Condition aggravated, Death, Dyspnoea, Respiratory arrest, Resuscitation, Syncope, Cardiac assistance device user, Cardiac disorder, Mechanical ventilation, Airway patency device insertion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Metformin Glipizide Metoprolol
Current Illness: Shortness of breath for a week before his passing, he did not seek medical attention for this.
Preexisting Conditions: Cardiac History Hypertension Diabetes
Allergies: No
Diagnostic Lab Data: No
CDC 'Split Type':

Write-up: EMS reported sudden onset of shortness of breath, patient grabbed his chest and collapsed. He stopped breathing. Wife began CPR with chest compressions at 5:00. Fire dept. arrived resumed CPR and attached AED but there was no shock advise. They placed an OPA as well (inserted an airway) and started ventilation. Asystole was confirmed, they continued CPR. After 5:25 they gave 3 rounds Epineferin and ended CPR at 5:46. They also checked his blood sugar and it was 136. Possible reaction to covid vaccine. Possible death due to history of cardiac issues. His PCP is requesting an autopsy


Changed on 5/7/2021

VAERS ID: 1084419 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:Maine
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose increased, Cardiac arrest, Condition aggravated, Death, Dyspnoea, Respiratory arrest, Resuscitation, Syncope, Cardiac assistance device user, Cardiac disorder, Mechanical ventilation, Airway patency device insertion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Metformin Glipizide Metoprolol
Current Illness: Shortness of breath for a week before his passing, he did not seek medical attention for this.
Preexisting Conditions: Cardiac History Hypertension Diabetes
Allergies: No No
Diagnostic Lab Data: No
CDC 'Split Type':

Write-up: EMS reported sudden onset of shortness of breath, patient grabbed his chest and collapsed. He stopped breathing. Wife began CPR with chest compressions at 5:00. Fire dept. arrived resumed CPR and attached AED but there was no shock advise. They placed an OPA as well (inserted an airway) and started ventilation. Asystole was confirmed, they continued CPR. After 5:25 they gave 3 rounds Epineferin and ended CPR at 5:46. They also checked his blood sugar and it was 136. Possible reaction to covid vaccine. Possible death due to history of cardiac issues. His PCP is requesting an autopsy


Changed on 5/14/2021

VAERS ID: 1084419 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:Maine
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose increased, Cardiac arrest, Condition aggravated, Death, Dyspnoea, Respiratory arrest, Resuscitation, Syncope, Cardiac assistance device user, Cardiac disorder, Mechanical ventilation, Airway patency device insertion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Metformin Glipizide Metoprolol
Current Illness: Shortness of breath for a week before his passing, he did not seek medical attention for this.
Preexisting Conditions: Cardiac History Hypertension Diabetes
Allergies: No No
Diagnostic Lab Data: No
CDC 'Split Type':

Write-up: EMS reported sudden onset of shortness of breath, patient grabbed his chest and collapsed. He stopped breathing. Wife began CPR with chest compressions at 5:00. Fire dept. arrived resumed CPR and attached AED but there was no shock advise. They placed an OPA as well (inserted an airway) and started ventilation. Asystole was confirmed, they continued CPR. After 5:25 they gave 3 rounds Epineferin and ended CPR at 5:46. They also checked his blood sugar and it was 136. Possible reaction to covid vaccine. Possible death due to history of cardiac issues. His PCP is requesting an autopsy

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