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This is VAERS ID 1123247

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1123247
VAERS Form:2
Age:67.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-22
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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 - did list Eliquis as being taken.
Current Illness: none noted
Preexisting Conditions: unknown
Allergies: indicated none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Our agency was alerted that the patient passed away on 3/16/2021


Changed on 5/7/2021

VAERS ID: 1123247 Before After
VAERS Form:2
Age:67.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-22
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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 - did list Eliquis as being taken.
Current Illness: none noted
Preexisting Conditions: unknown
Allergies: indicated none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Our agency was alerted that the patient passed away on 3/16/2021


Changed on 5/14/2021

VAERS ID: 1123247 Before After
VAERS Form:2
Age:67.0
Sex:Female
Location:Michigan
Vaccinated:2021-03-22
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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 - did list Eliquis as being taken.
Current Illness: none noted
Preexisting Conditions: unknown
Allergies: indicated none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Our agency was alerted that the patient passed away on 3/16/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1123247&WAYBACKHISTORY=ON

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