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This is VAERS ID 1116400

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1116400
VAERS Form:2
Age:80.0
Sex:Male
Location:Minnesota
Vaccinated:2021-01-25
Onset:2021-03-17
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-17
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away within 60 days of receiving the COVID vaccine series


Changed on 5/7/2021

VAERS ID: 1116400 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Minnesota
Vaccinated:2021-01-25
Onset:2021-03-17
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-17
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away within 60 days of receiving the COVID vaccine series

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1116400&WAYBACKHISTORY=ON


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