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This is VAERS ID 1084685

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1084685
VAERS Form:2
Age:68.0
Sex:Male
Location:Maine
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-08
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: We received a phone call stating that the patient passed away overnight.


Changed on 5/7/2021

VAERS ID: 1084685 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Maine
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-08
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: We received a phone call stating that the patient passed away overnight.


Changed on 5/14/2021

VAERS ID: 1084685 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Maine
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-08
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: We received a phone call stating that the patient passed away overnight.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1084685&WAYBACKHISTORY=ON

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