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This is VAERS ID 1104815

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1104815
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-15
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death, COVID-19

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Seen in ED for positive COVID symptoms - discharged with instructions. Death 1/26/2021


Changed on 5/7/2021

VAERS ID: 1104815 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-15
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death, COVID-19

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Seen in ED for positive COVID symptoms - discharged with instructions. Death 1/26/2021


Changed on 5/14/2021

VAERS ID: 1104815 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-15
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death, COVID-19

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Seen in ED for positive COVID symptoms - discharged with instructions. Death 1/26/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1104815&WAYBACKHISTORY=ON

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