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This is VAERS ID 1115994

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1115994
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Apnoea, Death, Diarrhoea, Heart rate irregular, Lethargy, Malaise, Unresponsive to stimuli, Vomiting, Hypophagia, Illness

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: Tylenol, Ativan, Diabetic Tussin, Dulcolax, Garamycin, Glucerna, Haldol, Imodium, Milk of Magnesia, Nystatin topical, Risperdal, Senna S
Current Illness: The patient was on hospice for Alzheimer?s disease but no acute illnesses.
Preexisting Conditions: Alzheimer?s Disease, Parkinson?s disease, Diabetes
Allergies: None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: 03/02/21 the patient was visited by nurse. No signs of distress. Normal vitals. No GI concerns according to staff. Her appetite was her usual described as fair. She received her 2nd Moderna vaccination on 03/08/21. Within hour she because very ill according to facility staff. She began to vomit up to 5 times. Her stools because loose. She became more lethargic. She was started on compazine for the vomiting. Her oral intake was minimal. Her symptoms did not resolve and she was visited by the nurse again on 03/11/2021 where she was not very responsive. Her vitals included an irregular pulse and apnea noted in her breathing up to 15 seconds. She died on 03/12/21


Changed on 5/7/2021

VAERS ID: 1115994 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Apnoea, Death, Diarrhoea, Heart rate irregular, Lethargy, Malaise, Unresponsive to stimuli, Vomiting, Hypophagia, Illness

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: Tylenol, Ativan, Diabetic Tussin, Dulcolax, Garamycin, Glucerna, Haldol, Imodium, Milk of Magnesia, Nystatin topical, Risperdal, Senna S
Current Illness: The patient was on hospice for Alzheimer?s disease but no acute illnesses.
Preexisting Conditions: Alzheimer?s Disease, Parkinson?s disease, Diabetes
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: 03/02/21 the patient was visited by nurse. No signs of distress. Normal vitals. No GI concerns according to staff. Her appetite was her usual described as fair. She received her 2nd Moderna vaccination on 03/08/21. Within hour she because very ill according to facility staff. She began to vomit up to 5 times. Her stools because loose. She became more lethargic. She was started on compazine for the vomiting. Her oral intake was minimal. Her symptoms did not resolve and she was visited by the nurse again on 03/11/2021 where she was not very responsive. Her vitals included an irregular pulse and apnea noted in her breathing up to 15 seconds. She died on 03/12/21


Changed on 5/14/2021

VAERS ID: 1115994 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-08
Onset:2021-03-08
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Apnoea, Death, Diarrhoea, Heart rate irregular, Lethargy, Malaise, Unresponsive to stimuli, Vomiting, Hypophagia, Illness

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: Tylenol, Ativan, Diabetic Tussin, Dulcolax, Garamycin, Glucerna, Haldol, Imodium, Milk of Magnesia, Nystatin topical, Risperdal, Senna S
Current Illness: The patient was on hospice for Alzheimer?s disease but no acute illnesses.
Preexisting Conditions: Alzheimer?s Disease, Parkinson?s disease, Diabetes
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: 03/02/21 the patient was visited by nurse. No signs of distress. Normal vitals. No GI concerns according to staff. Her appetite was her usual described as fair. She received her 2nd Moderna vaccination on 03/08/21. Within hour she because very ill according to facility staff. She began to vomit up to 5 times. Her stools because loose. She became more lethargic. She was started on compazine for the vomiting. Her oral intake was minimal. Her symptoms did not resolve and she was visited by the nurse again on 03/11/2021 where she was not very responsive. Her vitals included an irregular pulse and apnea noted in her breathing up to 15 seconds. She died on 03/12/21

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