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This is VAERS ID 1117078

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1117078
VAERS Form:2
Age:89.0
Sex:Female
Location:California
Vaccinated:2021-03-11
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / N/A LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Arteriosclerosis, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Atenolol 50mg/day; unknown/various (B complex, metamucil tabs)
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient died approx. 5 hours after shot was administered. Cause of death reported is Atherosclerotic Cardiovascular Disease. The death certificate was signed by the county coroner without autopsy, based on the report by the onsite deputy coroner. No doctors or hospitals were involved. This report is FYI only; there has been no direct connection made between my mother''s death and the vaccine other than one followed shorty after the other.


Changed on 5/7/2021

VAERS ID: 1117078 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:California
Vaccinated:2021-03-11
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / N/A LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Arteriosclerosis, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Atenolol 50mg/day; unknown/various (B complex, metamucil tabs)
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient died approx. 5 hours after shot was administered. Cause of death reported is Atherosclerotic Cardiovascular Disease. The death certificate was signed by the county coroner without autopsy, based on the report by the onsite deputy coroner. No doctors or hospitals were involved. This report is FYI only; there has been no direct connection made between my mother''s death and the vaccine other than one followed shorty after the other.


Changed on 5/14/2021

VAERS ID: 1117078 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:California
Vaccinated:2021-03-11
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / N/A LA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Arteriosclerosis, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Atenolol 50mg/day; unknown/various (B complex, metamucil tabs)
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient died approx. 5 hours after shot was administered. Cause of death reported is Atherosclerotic Cardiovascular Disease. The death certificate was signed by the county coroner without autopsy, based on the report by the onsite deputy coroner. No doctors or hospitals were involved. This report is FYI only; there has been no direct connection made between my mother''s death and the vaccine other than one followed shorty after the other.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1117078&WAYBACKHISTORY=ON

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