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This is VAERS ID 1123329

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1123329
VAERS Form:2
Age:70.0
Sex:Male
Location:New York
Vaccinated:2021-03-21
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Dyspepsia, Respiration abnormal, Respiratory arrest, Pulseless electrical activity, Respiratory syncytial virus test negative, Influenza virus test negative, SARS-CoV-2 test negative

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
Current Illness: unknown
Preexisting Conditions: Aortic stenosis, DM2, COPD, HTN, CAD
Allergies: unknown
Diagnostic Lab Data: COVID negative, Flu Negative, RSV negative
CDC 'Split Type':

Write-up: Presented to Emergency department in cardiac arrest. Pt''s family reports patient complaining of indigestion throughout the night. Awakened this morning but returned to bed. Family noted his breathing became loud and then stopped. EMS called. Patient in PEA arrest when they arrived. Patient''s family reports he received COVID-19 vaccine day before via facility. I have notified the vaccine clinic and received the Lot number of the vaccine use when I called.

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