National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1112117

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1112117
VAERS Form:2
Age:88.0
Sex:Male
Location:Utah
Vaccinated:2021-03-09
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6206 / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Flank pain, Pyrexia, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: Multivitamin, Allergy Med, Vit C, Ativan, B-12, Celexa, Chelated Zinc, cholecalcifefol - Vit D3, Crestor, Furosemide, Haloperidol lactate, Keflex, losartan, mangnesium oxide, morphine concentrate, potassium chloride ER, Promethazine, Seleni
Current Illness: Frontal Lobe Dementia, Muscle Weakness, Edema, weight loss
Preexisting Conditions: same as 11.
Allergies: no known allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was a patient on hospice, had terminal dx of frontal lobe dementia. NP visited with patient on 03/10/2021, notable decline/flank pain, fever 101. Patient passed away on 03/12/21, Medical Director wanted this reported to VAERS d/t the vaccination was within 72hrs of the pts death.


Changed on 5/7/2021

VAERS ID: 1112117 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Utah
Vaccinated:2021-03-09
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6206 / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Flank pain, Pyrexia, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: Multivitamin, Allergy Med, Vit C, Ativan, B-12, Celexa, Chelated Zinc, cholecalcifefol - Vit D3, Crestor, Furosemide, Haloperidol lactate, Keflex, losartan, mangnesium oxide, morphine concentrate, potassium chloride ER, Promethazine, Seleni
Current Illness: Frontal Lobe Dementia, Muscle Weakness, Edema, weight loss
Preexisting Conditions: same as 11.
Allergies: no known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was a patient on hospice, had terminal dx of frontal lobe dementia. NP visited with patient on 03/10/2021, notable decline/flank pain, fever 101. Patient passed away on 03/12/21, Medical Director wanted this reported to VAERS d/t the vaccination was within 72hrs of the pts death.


Changed on 5/14/2021

VAERS ID: 1112117 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Utah
Vaccinated:2021-03-09
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6206 / 1 - / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Flank pain, Pyrexia, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: Multivitamin, Allergy Med, Vit C, Ativan, B-12, Celexa, Chelated Zinc, cholecalcifefol - Vit D3, Crestor, Furosemide, Haloperidol lactate, Keflex, losartan, mangnesium oxide, morphine concentrate, potassium chloride ER, Promethazine, Seleni
Current Illness: Frontal Lobe Dementia, Muscle Weakness, Edema, weight loss
Preexisting Conditions: same as 11.
Allergies: no known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was a patient on hospice, had terminal dx of frontal lobe dementia. NP visited with patient on 03/10/2021, notable decline/flank pain, fever 101. Patient passed away on 03/12/21, Medical Director wanted this reported to VAERS d/t the vaccination was within 72hrs of the pts death.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1112117&WAYBACKHISTORY=ON


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