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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1115715



Case Details

VAERS ID: 1115715 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-23
Onset:2021-03-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Death, Fall, Malaise
SMQs:, Guillain-Barre syndrome (broad), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, ASA, atorvastatin, carvedilol, ferrous sulfate, Furosimide, gabapentin, metformin, spironolactone, tamsulosin, tradjenta,
Current Illness: Unknown
Preexisting Conditions: Diabetes, dementia, HTN, MI, CHF, Pacemaker
Allergies: No reported allergies
Diagnostic Lab Data: ED workup
CDC Split Type:

Write-up: Family, daughter, reports that patient felt "a little sick" on 2/24/21 and "sick" on 2/25/21. She reports that approximately 1 week later her father had weakness and and frequent falls, was evaluated in the E.D. and ultimately admitted to hospital (3/4-3/15) Patient was discharged to nursing home where he died on 3/16/21.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1115715

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