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This is VAERS ID 1120756

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1120756
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046AZ1A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Dyspnoea, Epistaxis, Mouth haemorrhage, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC 'Split Type': CA134B1001

Write-up: On Friday night, 3/19/21, patient spiked a fever, had shortness of breath, and had blood coming out of his nose and mouth per patient''s daughter-in law. 9-1-1 was called, paramedics arrived at the home at 5AM on Saturday, 3/20/21 per patient''s daughter. Patient died.


Changed on 5/7/2021

VAERS ID: 1120756 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046AZ1A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Dyspnoea, Epistaxis, Mouth haemorrhage, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: High Cholesterol
Allergies: Unknown Unknown
Diagnostic Lab Data: Unknown
CDC 'Split Type': CA134B1001

Write-up: On Friday night, 3/19/21, patient spiked a fever, had shortness of breath, and had blood coming out of his nose and mouth per patient''s daughter-in law. 9-1-1 was called, paramedics arrived at the home at 5AM on Saturday, 3/20/21 per patient''s daughter. Patient died.


Changed on 5/14/2021

VAERS ID: 1120756 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-03-18
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046AZ1A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Dyspnoea, Epistaxis, Mouth haemorrhage, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: High Cholesterol
Allergies: Unknown Unknown
Diagnostic Lab Data: Unknown
CDC 'Split Type': CA134B1001

Write-up: On Friday night, 3/19/21, patient spiked a fever, had shortness of breath, and had blood coming out of his nose and mouth per patient''s daughter-in law. 9-1-1 was called, paramedics arrived at the home at 5AM on Saturday, 3/20/21 per patient''s daughter. Patient died.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1120756&WAYBACKHISTORY=ON

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