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This is VAERS ID 1085019

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1085019
VAERS Form:2
Age:65.0
Sex:Female
Location:Washington
Vaccinated:2020-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Death

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: Multi vitamin, promethazine 25 mg, omeprazole 20 mg, cyclobenzaprine, 10 mg, oxycodone/APAP 5/325mg, gabapentin 800 mg, simvastatin 20 mg tab, metformin 1000 mg tab, nortriptyline 50 mg cap, zolpidem 10 mg tab, Ketorolac 60 mg injection 2 t
Current Illness: Chronic pain, HTN, DM, Cervicalgia, nausea, insomnia
Preexisting Conditions: Tobacco abuse, HTN, Diabetes mellitus, DJD, Cervicalgia, osteoarthritis, chronic pain, opioid use, diabetic polyneuropathy, carpal tunnel syndrome bilaterally, atopic dermatitis, bursitis , history of DVT, LE edema, chronic nausea, hyperlipidemia, insomnia,
Allergies: Benzodiazepines, celecoxib, codeine, diphenhydramine HCL, inositol Niacinate, Metaxalone, Niacinamide, oxycodone HCL, ASA, horse/equine containing products,, erythromycin base products, shellfish derived, bee venom
Diagnostic Lab Data: Unknown if autopsy will be performed.
CDC 'Split Type':

Write-up: Had vaccine on 3/3/2021 at approximately 1 PM. She was found on her couch deceased on 3/8/2021. Possible death on 3/5/2021. She called her sister and told sister that back hurt worse than usual and she would lay on the couch and rest. This is where she was found. Unknown if from vaccine, but due to vaccination on Wednesday proceeding her death, report is being filed.


Changed on 5/7/2021

VAERS ID: 1085019 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Washington
Vaccinated:2020-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Death

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: Multi vitamin, promethazine 25 mg, omeprazole 20 mg, cyclobenzaprine, 10 mg, oxycodone/APAP 5/325mg, gabapentin 800 mg, simvastatin 20 mg tab, metformin 1000 mg tab, nortriptyline 50 mg cap, zolpidem 10 mg tab, Ketorolac 60 mg injection 2 t
Current Illness: Chronic pain, HTN, DM, Cervicalgia, nausea, insomnia
Preexisting Conditions: Tobacco abuse, HTN, Diabetes mellitus, DJD, Cervicalgia, osteoarthritis, chronic pain, opioid use, diabetic polyneuropathy, carpal tunnel syndrome bilaterally, atopic dermatitis, bursitis , history of DVT, LE edema, chronic nausea, hyperlipidemia, insomnia,
Allergies: Benzodiazepines, celecoxib, codeine, diphenhydramine HCL, inositol Niacinate, Metaxalone, Niacinamide, oxycodone HCL, ASA, horse/equine containing products,, erythromycin base products, shellfish derived, bee venom venom
Diagnostic Lab Data: Unknown if autopsy will be performed.
CDC 'Split Type':

Write-up: Had vaccine on 3/3/2021 at approximately 1 PM. She was found on her couch deceased on 3/8/2021. Possible death on 3/5/2021. She called her sister and told sister that back hurt worse than usual and she would lay on the couch and rest. This is where she was found. Unknown if from vaccine, but due to vaccination on Wednesday proceeding her death, report is being filed.


Changed on 5/14/2021

VAERS ID: 1085019 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Washington
Vaccinated:2020-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Death

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: Multi vitamin, promethazine 25 mg, omeprazole 20 mg, cyclobenzaprine, 10 mg, oxycodone/APAP 5/325mg, gabapentin 800 mg, simvastatin 20 mg tab, metformin 1000 mg tab, nortriptyline 50 mg cap, zolpidem 10 mg tab, Ketorolac 60 mg injection 2 t
Current Illness: Chronic pain, HTN, DM, Cervicalgia, nausea, insomnia
Preexisting Conditions: Tobacco abuse, HTN, Diabetes mellitus, DJD, Cervicalgia, osteoarthritis, chronic pain, opioid use, diabetic polyneuropathy, carpal tunnel syndrome bilaterally, atopic dermatitis, bursitis , history of DVT, LE edema, chronic nausea, hyperlipidemia, insomnia,
Allergies: Benzodiazepines, celecoxib, codeine, diphenhydramine HCL, inositol Niacinate, Metaxalone, Niacinamide, oxycodone HCL, ASA, horse/equine containing products,, erythromycin base products, shellfish derived, bee venom venom
Diagnostic Lab Data: Unknown if autopsy will be performed.
CDC 'Split Type':

Write-up: Had vaccine on 3/3/2021 at approximately 1 PM. She was found on her couch deceased on 3/8/2021. Possible death on 3/5/2021. She called her sister and told sister that back hurt worse than usual and she would lay on the couch and rest. This is where she was found. Unknown if from vaccine, but due to vaccination on Wednesday proceeding her death, report is being filed.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1085019&WAYBACKHISTORY=ON

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