National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1088184

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1088184
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-03-06
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: Furosemide, Omeprazole, Xarelto, Vitamin D3, Propranolol, Sucralfate, Spironolactone
Current Illness: Unknown
Preexisting Conditions: Seizures, unknown
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead on 3/9/21 approximately 72 hours after receiving vaccination. Unknown symptoms prior.


Changed on 5/7/2021

VAERS ID: 1088184 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-03-06
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: Furosemide, Omeprazole, Xarelto, Vitamin D3, Propranolol, Sucralfate, Spironolactone
Current Illness: Unknown
Preexisting Conditions: Seizures, unknown
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead on 3/9/21 approximately 72 hours after receiving vaccination. Unknown symptoms prior.


Changed on 5/14/2021

VAERS ID: 1088184 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:California
Vaccinated:2021-03-06
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: Furosemide, Omeprazole, Xarelto, Vitamin D3, Propranolol, Sucralfate, Spironolactone
Current Illness: Unknown
Preexisting Conditions: Seizures, unknown
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead on 3/9/21 approximately 72 hours after receiving vaccination. Unknown symptoms prior.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1088184&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166