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This is VAERS ID 1124363

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1124363
VAERS Form:2
Age:65.0
Sex:Male
Location:Hawaii
Vaccinated:2021-03-06
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA W1010A21A / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Resuscitation, Syncope, Sudden cardiac death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
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: Lipitor 10 mg tablet 1 tab(s) orally once a day at bedtime Benicar HCT 25 mg-40 mg tablet 1 tab(s) orally once a day metformin 1000 mg tablet 1 tab(s) orally BID Tenormin 50 mg tablet 1 tab(s) orally once a day ASA 81mg enteric
Current Illness: none
Preexisting Conditions: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, alcohol abuse
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient died at home. apparently he awoke in the middle of the night and asked for help, then collapsed. CPR failed. patient and family did not want an autopsy. suspect sudden cardiac death


Changed on 5/7/2021

VAERS ID: 1124363 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Hawaii
Vaccinated:2021-03-06
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA W1010A21A / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Resuscitation, Syncope, Sudden cardiac death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
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: Lipitor 10 mg tablet 1 tab(s) orally once a day at bedtime Benicar HCT 25 mg-40 mg tablet 1 tab(s) orally once a day metformin 1000 mg tablet 1 tab(s) orally BID Tenormin 50 mg tablet 1 tab(s) orally once a day ASA 81mg enteric
Current Illness: none
Preexisting Conditions: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, alcohol abuse
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient died at home. apparently he awoke in the middle of the night and asked for help, then collapsed. CPR failed. patient and family did not want an autopsy. suspect sudden cardiac death

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124363&WAYBACKHISTORY=ON


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