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This is VAERS ID 1109427

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1109427
VAERS Form:2
Age:81.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-02-26
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dyspnoea, Fatigue, Heart rate decreased, Lethargy, Memory impairment, Nightmare, Continuous positive airway pressure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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,K-Tab/Potassium, Eliquis, Amlodipine Besylate, Lisinopril, Gabapentin,Lipator
Current Illness: No illnesses
Preexisting Conditions: Atrial Fibrillation High Blood Pressure Diabetes Sleep Apnea
Allergies: Iodine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Moderna Covid-19 Vaccine EUA After receiving the first vaccine, started making gasping noises at night, lethargy, fit bit would not register sleep at night, some breathing issues during waking hours. HR observed to decrease to under 40 over the last week of his life. 5 days after 2nd vaccine had extreme fatigue, nightmares, forgot to take regular meds in the morning, 6 days after he woke up very confused and had nightmares and 7 days after vaccination woke up late, exhausted, with shortness of breath all day and refused to go to ER. Went to bed early and died in the night with his CPAP machine on.


Changed on 5/7/2021

VAERS ID: 1109427 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-02-26
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dyspnoea, Fatigue, Heart rate decreased, Lethargy, Memory impairment, Nightmare, Continuous positive airway pressure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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,K-Tab/Potassium, Eliquis, Amlodipine Besylate, Lisinopril, Gabapentin,Lipator
Current Illness: No illnesses
Preexisting Conditions: Atrial Fibrillation High Blood Pressure Diabetes Sleep Apnea
Allergies: Iodine Iodine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Moderna Covid-19 Vaccine EUA After receiving the first vaccine, started making gasping noises at night, lethargy, fit bit would not register sleep at night, some breathing issues during waking hours. HR observed to decrease to under 40 over the last week of his life. 5 days after 2nd vaccine had extreme fatigue, nightmares, forgot to take regular meds in the morning, 6 days after he woke up very confused and had nightmares and 7 days after vaccination woke up late, exhausted, with shortness of breath all day and refused to go to ER. Went to bed early and died in the night with his CPAP machine on.


Changed on 5/14/2021

VAERS ID: 1109427 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-02-26
Onset:2021-02-26
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dyspnoea, Fatigue, Heart rate decreased, Lethargy, Memory impairment, Nightmare, Continuous positive airway pressure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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,K-Tab/Potassium, Eliquis, Amlodipine Besylate, Lisinopril, Gabapentin,Lipator
Current Illness: No illnesses
Preexisting Conditions: Atrial Fibrillation High Blood Pressure Diabetes Sleep Apnea
Allergies: Iodine Iodine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Moderna Covid-19 Vaccine EUA After receiving the first vaccine, started making gasping noises at night, lethargy, fit bit would not register sleep at night, some breathing issues during waking hours. HR observed to decrease to under 40 over the last week of his life. 5 days after 2nd vaccine had extreme fatigue, nightmares, forgot to take regular meds in the morning, 6 days after he woke up very confused and had nightmares and 7 days after vaccination woke up late, exhausted, with shortness of breath all day and refused to go to ER. Went to bed early and died in the night with his CPAP machine on.

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