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This is VAERS ID 1124383

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1124383
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC 'Split Type':

Write-up: DEATH Narrative: Events surrounding patient''s death are unknown- nothing is documented in medical record regarding event. Causality of death is unknown. This event is being reported due to the timing of the death in relation to the receipt of vaccine (4 days).


Changed on 5/7/2021

VAERS ID: 1124383 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC 'Split Type':

Write-up: DEATH Narrative: Events surrounding patient''s death are unknown- nothing is documented in medical record regarding event. Causality of death is unknown. This event is being reported due to the timing of the death in relation to the receipt of vaccine (4 days).


Changed on 5/14/2021

VAERS ID: 1124383 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC 'Split Type':

Write-up: DEATH Narrative: Events surrounding patient''s death are unknown- nothing is documented in medical record regarding event. Causality of death is unknown. This event is being reported due to the timing of the death in relation to the receipt of vaccine (4 days).

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124383&WAYBACKHISTORY=ON

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