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This is VAERS ID 1126293

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1126293
VAERS Form:2
Age:75.0
Sex:Male
Location:Montana
Vaccinated:2021-03-11
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-21
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: Allopurinol Colcrys
Current Illness:
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death 10 days after receiving first moderna covid vaccination. Was not told by patients family cause of death, unclear if there is a link between vaccination or not.

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