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This is VAERS ID 1113647

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1113647
VAERS Form:2
Age:81.0
Sex:Male
Location:California
Vaccinated:2021-03-01
Onset:2021-03-18
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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: Coreg Lasix
Current Illness: Liver failure
Preexisting Conditions: Liver failure
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died 3 days after vaccination


Changed on 5/7/2021

VAERS ID: 1113647 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:California
Vaccinated:2021-03-01
Onset:2021-03-18
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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: Coreg Lasix
Current Illness: Liver failure
Preexisting Conditions: Liver failure
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died 3 days after vaccination

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1113647&WAYBACKHISTORY=ON


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