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This is VAERS ID 1109696

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1109696
VAERS Form:2
Age:64.0
Sex:Male
Location:New York
Vaccinated:2020-12-31
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrial fibrillation, Blood lactate dehydrogenase increased, Death, Dyspnoea, Sepsis, Serum ferritin increased, Staphylococcal bacteraemia, Metabolic function test normal, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: atorvastatin, omeprazole, folic acid, furosemide, methotrexate weekly, metoprolol, ozempic
Current Illness: tested positive for covid 19 on 12/14/2021
Preexisting Conditions: HTN, DM, arthritis, ckd , hyperlipidemia
Allergies: None
Diagnostic Lab Data: LDH 8396, Ferritin 25902, CMP on arrival normal. Was known covid positive since 12/14.
CDC 'Split Type':

Write-up: Pt presented to the ER on 1/4 2021 with worsening sob, found to have acute ST elevation MI and new rapid atrial fib with RVR. He tested positive for covid 19 requiring new oxygen and received his first pfizer vaccine on 12/31. He was acutely transferred to rochester general hospital. He progressed to multiorgan failure, sepsis, mrsa bacteremia and died on 1/14/2021


Changed on 5/7/2021

VAERS ID: 1109696 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:New York
Vaccinated:2020-12-31
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrial fibrillation, Blood lactate dehydrogenase increased, Death, Dyspnoea, Sepsis, Serum ferritin increased, Staphylococcal bacteraemia, Metabolic function test normal, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: atorvastatin, omeprazole, folic acid, furosemide, methotrexate weekly, metoprolol, ozempic
Current Illness: tested positive for covid 19 on 12/14/2021
Preexisting Conditions: HTN, DM, arthritis, ckd , hyperlipidemia
Allergies: None None
Diagnostic Lab Data: LDH 8396, Ferritin 25902, CMP on arrival normal. Was known covid positive since 12/14.
CDC 'Split Type':

Write-up: Pt presented to the ER on 1/4 2021 with worsening sob, found to have acute ST elevation MI and new rapid atrial fib with RVR. He tested positive for covid 19 requiring new oxygen and received his first pfizer vaccine on 12/31. He was acutely transferred to rochester general hospital. He progressed to multiorgan failure, sepsis, mrsa bacteremia and died on 1/14/2021


Changed on 5/14/2021

VAERS ID: 1109696 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:New York
Vaccinated:2020-12-31
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrial fibrillation, Blood lactate dehydrogenase increased, Death, Dyspnoea, Sepsis, Serum ferritin increased, Staphylococcal bacteraemia, Metabolic function test normal, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: atorvastatin, omeprazole, folic acid, furosemide, methotrexate weekly, metoprolol, ozempic
Current Illness: tested positive for covid 19 on 12/14/2021
Preexisting Conditions: HTN, DM, arthritis, ckd , hyperlipidemia
Allergies: None None
Diagnostic Lab Data: LDH 8396, Ferritin 25902, CMP on arrival normal. Was known covid positive since 12/14.
CDC 'Split Type':

Write-up: Pt presented to the ER on 1/4 2021 with worsening sob, found to have acute ST elevation MI and new rapid atrial fib with RVR. He tested positive for covid 19 requiring new oxygen and received his first pfizer vaccine on 12/31. He was acutely transferred to rochester general hospital. He progressed to multiorgan failure, sepsis, mrsa bacteremia and died on 1/14/2021

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