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This is VAERS ID 1122742

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1122742
VAERS Form:2
Age:89.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: BENADRYL; CLOPIDOGREL BISULFATE; CALCITRIOL; MELATONIN; MAGNESIUM; SIMVASTATIN; TERAZOSIN HCL; TIZANIDINE HCL; VITAMIN C [ASCORBIC ACID]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy (he has a long list of allergies); Neck pain; Penicillin allergy (Allergic to Penicillin); Sleep disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USPFIZER INC2021293310

Write-up: He died around 5 o clock; This is a spontaneous report from a contactable consumer (patient''s wife). An 89-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), via an unspecified route of administration on 12Mar2021 13:00 at a single dose (lot number was reported as NEEU200, the reporter did not know if its 2 or Z) for COVID-19 immunization. Medical history allergic to Penicillin, has a long list of allergies, neck pain and sleep disorder (sleep aid). Concomitant medications included diphenhydramine hydrochloride (BENADRYL), clopidogrel bisulfate, calcitriol, melatonin (MELATONIN) taken for sleep aid, Phillips Laxative tablet Magnesium (not appropriately paraphrased and clarified, as reported), simvastatin, terazosin hydrochloride, tizanidine hydrochloride (TIZANIDINE HCL) for when he had the pain in neck (he didn''t take that hardly ever), vitamin C [ascorbic acid] and Multivitamin one a day. On Friday 12Mar2021, the reporter and the patient went to get the Covid shot. Their appointment was at 12:30 but they were in line long time before they got the shot. They got the shot around 13:00 and then they have to wait 15 minutes before they could leave. They drove up, they were ready to shoot us with the needle and they asked the patient, asked was he allergic to anything and the reporter answered for him and said yes, Penicillin and other long list and then they gave him the shot. They never did go over his allergies. They got home about 13:30, so which would take us about that long to get home. The patient died around 5 o clock and the reporter didn''t know if this was connected or not with his death. The patient died on 12Mar2021. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: This case of death was provided with minimal details and autopsy results not available. However, drug causality cannot be completely excluded for BNT162B2 injection, only due to plausible chronological relation. Otherwise, information received was so limited to prevent a thorough medical assessment for patient death. The impact of this report on the benefit/risk profile of the Pfizer drugs is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: He died around 5 o clock


Changed on 5/7/2021

VAERS ID: 1122742 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: BENADRYL; CLOPIDOGREL BISULFATE; CALCITRIOL; MELATONIN; MAGNESIUM; SIMVASTATIN; TERAZOSIN HCL; TIZANIDINE HCL; VITAMIN C [ASCORBIC ACID]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy (he has a long list of allergies); Neck pain; Penicillin allergy (Allergic to Penicillin); Sleep disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USPFIZER INC2021293310

Write-up: He died around 5 o clock; This is a spontaneous report from a contactable consumer (patient''s wife). An 89-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), via an unspecified route of administration on 12Mar2021 13:00 at a single dose (lot number was reported as NEEU200, the reporter did not know if its 2 or Z) for COVID-19 immunization. Medical history allergic to Penicillin, has a long list of allergies, neck pain and sleep disorder (sleep aid). Concomitant medications included diphenhydramine hydrochloride (BENADRYL), clopidogrel bisulfate, calcitriol, melatonin (MELATONIN) taken for sleep aid, Phillips Laxative tablet Magnesium (not appropriately paraphrased and clarified, as reported), simvastatin, terazosin hydrochloride, tizanidine hydrochloride (TIZANIDINE HCL) for when he had the pain in neck (he didn''t take that hardly ever), vitamin C [ascorbic acid] and Multivitamin one a day. On Friday 12Mar2021, the reporter and the patient went to get the Covid shot. Their appointment was at 12:30 but they were in line long time before they got the shot. They got the shot around 13:00 and then they have to wait 15 minutes before they could leave. They drove up, they were ready to shoot us with the needle and they asked the patient, asked was he allergic to anything and the reporter answered for him and said yes, Penicillin and other long list and then they gave him the shot. They never did go over his allergies. They got home about 13:30, so which would take us about that long to get home. The patient died around 5 o clock and the reporter didn''t know if this was connected or not with his death. The patient died on 12Mar2021. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: This case of death was provided with minimal details and autopsy results not available. However, drug causality cannot be completely excluded for BNT162B2 injection, only due to plausible chronological relation. Otherwise, information received was so limited to prevent a thorough medical assessment for patient death. The impact of this report on the benefit/risk profile of the Pfizer drugs is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: He died around 5 o clock


Changed on 5/14/2021

VAERS ID: 1122742 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Tennessee
Vaccinated:2021-03-12
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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: BENADRYL; CLOPIDOGREL BISULFATE; CALCITRIOL; MELATONIN; MAGNESIUM; SIMVASTATIN; TERAZOSIN HCL; TIZANIDINE HCL; VITAMIN C [ASCORBIC ACID]
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy (he has a long list of allergies); Neck pain; Penicillin allergy (Allergic to Penicillin); Sleep disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USPFIZER INC2021293310

Write-up: He died around 5 o clock; This is a spontaneous report from a contactable consumer (patient''s wife). An 89-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), via an unspecified route of administration on 12Mar2021 13:00 at a single dose (lot number was reported as NEEU200, the reporter did not know if its 2 or Z) for COVID-19 immunization. Medical history allergic to Penicillin, has a long list of allergies, neck pain and sleep disorder (sleep aid). Concomitant medications included diphenhydramine hydrochloride (BENADRYL), clopidogrel bisulfate, calcitriol, melatonin (MELATONIN) taken for sleep aid, Phillips Laxative tablet Magnesium (not appropriately paraphrased and clarified, as reported), simvastatin, terazosin hydrochloride, tizanidine hydrochloride (TIZANIDINE HCL) for when he had the pain in neck (he didn''t take that hardly ever), vitamin C [ascorbic acid] and Multivitamin one a day. On Friday 12Mar2021, the reporter and the patient went to get the Covid shot. Their appointment was at 12:30 but they were in line long time before they got the shot. They got the shot around 13:00 and then they have to wait 15 minutes before they could leave. They drove up, they were ready to shoot us with the needle and they asked the patient, asked was he allergic to anything and the reporter answered for him and said yes, Penicillin and other long list and then they gave him the shot. They never did go over his allergies. They got home about 13:30, so which would take us about that long to get home. The patient died around 5 o clock and the reporter didn''t know if this was connected or not with his death. The patient died on 12Mar2021. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: This case of death was provided with minimal details and autopsy results not available. However, drug causality cannot be completely excluded for BNT162B2 injection, only due to plausible chronological relation. Otherwise, information received was so limited to prevent a thorough medical assessment for patient death. The impact of this report on the benefit/risk profile of the Pfizer drugs is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: He died around 5 o clock

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