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This is VAERS ID 1112701

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1112701
VAERS Form:2
Age:72.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: warfarin, famotidine
Current Illness:
Preexisting Conditions:
Allergies: penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received COVID19 shot on 3/12/2021. Pt passed away on 3/15/2021. Dr called us to inform us that our patient had passed away but he did not believe it was caused by the vaccination at this time.


Changed on 5/7/2021

VAERS ID: 1112701 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: warfarin, famotidine
Current Illness:
Preexisting Conditions:
Allergies: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received COVID19 shot on 3/12/2021. Pt passed away on 3/15/2021. Dr called us to inform us that our patient had passed away but he did not believe it was caused by the vaccination at this time.


Changed on 5/14/2021

VAERS ID: 1112701 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: warfarin, famotidine
Current Illness:
Preexisting Conditions:
Allergies: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received COVID19 shot on 3/12/2021. Pt passed away on 3/15/2021. Dr called us to inform us that our patient had passed away but he did not believe it was caused by the vaccination at this time.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1112701&WAYBACKHISTORY=ON


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