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This is VAERS ID 1123847

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1123847
VAERS Form:2
Age:59.0
Sex:Male
Location:California
Vaccinated:2021-03-15
Onset:2021-03-16
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-16
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:
Current Illness:
Preexisting Conditions: DM, HTN, CHF, ESRD
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient had no reactions to first vaccine post dialysis. The morning after the patient received the vaccine, patient expired at home. Police stated that the death was vaccine related.


Changed on 5/7/2021

VAERS ID: 1123847 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:California
Vaccinated:2021-03-15
Onset:2021-03-16
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-16
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:
Current Illness:
Preexisting Conditions: DM, HTN, CHF, ESRD
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient had no reactions to first vaccine post dialysis. The morning after the patient received the vaccine, patient expired at home. Police stated that the death was vaccine related.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1123847&WAYBACKHISTORY=ON


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