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This is VAERS ID 1124688

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1124688
VAERS Form:2
Age:81.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-17
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN N/A / 1 UN / UN

Administered by: Private      Purchased by: ??
Symptoms: Sudden 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: Atorvastatin, Levothyroxine, Novolog, Iron ,Lisinopril, Aspirin,
Current Illness: Insulin Dependent DM, HTN, Hypercholesterolemia, Underweight, Hypothyroidism
Preexisting Conditions: As above
Allergies: None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Sudden death March 20, 2021


Changed on 5/7/2021

VAERS ID: 1124688 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-17
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN N/A / 1 UN / UN

Administered by: Private      Purchased by: ??
Symptoms: Sudden 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: Atorvastatin, Levothyroxine, Novolog, Iron ,Lisinopril, Aspirin,
Current Illness: Insulin Dependent DM, HTN, Hypercholesterolemia, Underweight, Hypothyroidism
Preexisting Conditions: As above
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Sudden death March 20, 2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124688&WAYBACKHISTORY=ON


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