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This is VAERS ID 1122393

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1122393
VAERS Form:2
Age:66.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-03
Onset:2021-03-18
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cheyne-Stokes respiration, Death, Diet refusal, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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: Death Narrative: Around the end of January 2021, patient was admitted to a home hospice program due to worsening of patient''s Parkinson''s Disease and Dementia. It was noted on the hospice programs Plan of Care that patient had severe, progressive dysphagia due to disease. Patient lost 20 pounds over the last 2 months prior to admission to hospice program. Patient had severe tremors, dystonia, and was dyspneic with minimal exertion. Patient received Moderna''s Covid vaccine on 3/3/21. On 3/13/21, patient got progressively worse. He stopped eating and drinking and started to exhibit Cheyne-Stokes breathing. Hospice nurse noted that patient only had a few days remaining. On 3/18/21, patient passed away.


Changed on 5/7/2021

VAERS ID: 1122393 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-03
Onset:2021-03-18
Submitted:0000-00-00
Entered:2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cheyne-Stokes respiration, Death, Diet refusal, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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: Death Narrative: Around the end of January 2021, patient was admitted to a home hospice program due to worsening of patient''s Parkinson''s Disease and Dementia. It was noted on the hospice programs Plan of Care that patient had severe, progressive dysphagia due to disease. Patient lost 20 pounds over the last 2 months prior to admission to hospice program. Patient had severe tremors, dystonia, and was dyspneic with minimal exertion. Patient received Moderna''s Covid vaccine on 3/3/21. On 3/13/21, patient got progressively worse. He stopped eating and drinking and started to exhibit Cheyne-Stokes breathing. Hospice nurse noted that patient only had a few days remaining. On 3/18/21, patient passed away.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1122393&WAYBACKHISTORY=ON


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