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This is VAERS ID 1115348

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1115348
VAERS Form:2
Age:
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: no adverse event, Continue: [UNK], Comment: No medical history reported
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: death; A spontaneous report was received from a HCP concerning about a 86 years old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history was not reported. Concomitant medications were not reported. On 05 Mar 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number: 026A21A) via intramuscular in left deltoid for prophylaxis of COVID-19 infection. On 06 Mar 2021 the patient died next day after vaccination, who left quite well after vaccination from the facility, the reason for death is not known. Treatment information was not provided. Action taken with mRNA-1273 in response to the event is not applicable. The outcomes of all the event is not applicable.; Reporter''s Comments: This is a case of death in a 86 years old female patient, with unknown past medical hx or current co morbid conditions and concomitant medications, who died one day after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


Changed on 5/7/2021

VAERS ID: 1115348 Before After
VAERS Form:2
Age:
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: no adverse event, Continue: [UNK], Comment: No medical history reported
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: death; A spontaneous report was received from a HCP concerning about a 86 years old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history was not reported. Concomitant medications were not reported. On 05 Mar 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number: 026A21A) via intramuscular in left deltoid for prophylaxis of COVID-19 infection. On 06 Mar 2021 the patient died next day after vaccination, who left quite well after vaccination from the facility, the reason for death is not known. Treatment information was not provided. Action taken with mRNA-1273 in response to the event is not applicable. The outcomes of all the event is not applicable.; Reporter''s Comments: This is a case of death in a 86 years old female patient, with unknown past medical hx or current co morbid conditions and concomitant medications, who died one day after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


Changed on 5/14/2021

VAERS ID: 1115348 Before After
VAERS Form:2
Age:
Sex:Female
Location:North Carolina
Vaccinated:2021-03-05
Onset:2021-03-06
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
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:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: no adverse event, Continue: [UNK], Comment: No medical history reported
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: death; A spontaneous report was received from a HCP concerning about a 86 years old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history was not reported. Concomitant medications were not reported. On 05 Mar 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number: 026A21A) via intramuscular in left deltoid for prophylaxis of COVID-19 infection. On 06 Mar 2021 the patient died next day after vaccination, who left quite well after vaccination from the facility, the reason for death is not known. Treatment information was not provided. Action taken with mRNA-1273 in response to the event is not applicable. The outcomes of all the event is not applicable.; Reporter''s Comments: This is a case of death in a 86 years old female patient, with unknown past medical hx or current co morbid conditions and concomitant medications, who died one day after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1115348&WAYBACKHISTORY=ON

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