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This is VAERS ID 1116099

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1116099
VAERS Form:2
Age:54.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-13
Onset:2021-03-16
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-16
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Cardiac Arrest Narrative: Patient received vaccine at 1209 on 3/13/2021, observed for 15min no reaction noted. Later that evening patient was not feeling well presented to ER where he was admitted. Had cardiac arrest during hospitalization on 3/16/2021 where patient passed away. Had a Hx of CHF, A-Fib, had a cardiac stent placement in 2020..


Changed on 5/7/2021

VAERS ID: 1116099 Before After
VAERS Form:2
Age:54.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-13
Onset:2021-03-16
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-16
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Cardiac Arrest Narrative: Patient received vaccine at 1209 on 3/13/2021, observed for 15min no reaction noted. Later that evening patient was not feeling well presented to ER where he was admitted. Had cardiac arrest during hospitalization on 3/16/2021 where patient passed away. Had a Hx of CHF, A-Fib, had a cardiac stent placement in 2020..

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1116099&WAYBACKHISTORY=ON


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