National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1116407

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1116407
VAERS Form:2
Age:59.0
Sex:Male
Location:Kansas
Vaccinated:2021-02-26
Onset:2021-02-27
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 16     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient got sick over the weekend. Went to facility on 03/02/2021 and then passed on 03/18/2021


Changed on 5/7/2021

VAERS ID: 1116407 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Kansas
Vaccinated:2021-02-26
Onset:2021-02-27
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 16     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient got sick over the weekend. Went to facility on 03/02/2021 and then passed on 03/18/2021


Changed on 5/14/2021

VAERS ID: 1116407 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Kansas
Vaccinated:2021-02-26
Onset:2021-02-27
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 16     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient got sick over the weekend. Went to facility on 03/02/2021 and then passed on 03/18/2021

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1116407&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166