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This is VAERS ID 1126609

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1126609
VAERS Form:2
Age:62.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-17
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Military      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Haemoglobin normal, Platelet count decreased, Red blood cell count normal, Thrombosis, White blood cell count increased, Drug screen negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none known by family who showed up at ED.
Current Illness: ETOH ABUSE, TOBACCO ABUSE, DIABETES,
Preexisting Conditions: DIABETES, TOBACCO AND ETOH ABUSE, SOME UNKNOWN LIVER DISEASE BY FAMILY REPORT-ON ONE KNOWS THE NAME OF IT.
Allergies: none known
Diagnostic Lab Data: CBC: WBC 12.8, RBC 4.82, HGB,15.0, HCT 46.0, PLATELETS 29 (LL)-BLOOD WAS CLOTTED, PT WAS DOA. DRUG SCREEN ALL NEGATIVE
CDC 'Split Type':

Write-up: CARDIOPULMONARY ARREST 2 DAYS AFTER RECIEVING SECOND MODERNA DOSE


Changed on 5/7/2021

VAERS ID: 1126609 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-17
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Military      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Death, Haemoglobin normal, Platelet count decreased, Red blood cell count normal, Thrombosis, White blood cell count increased, Drug screen negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none known by family who showed up at ED.
Current Illness: ETOH ABUSE, TOBACCO ABUSE, DIABETES,
Preexisting Conditions: DIABETES, TOBACCO AND ETOH ABUSE, SOME UNKNOWN LIVER DISEASE BY FAMILY REPORT-ON ONE KNOWS THE NAME OF IT.
Allergies: none known known
Diagnostic Lab Data: CBC: WBC 12.8, RBC 4.82, HGB,15.0, HCT 46.0, PLATELETS 29 (LL)-BLOOD WAS CLOTTED, PT WAS DOA. DRUG SCREEN ALL NEGATIVE
CDC 'Split Type':

Write-up: CARDIOPULMONARY ARREST 2 DAYS AFTER RECIEVING SECOND MODERNA DOSE

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1126609&WAYBACKHISTORY=ON


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