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From the 9/3/2021 release of VAERS data:

This is VAERS ID 1127361



Case Details

VAERS ID: 1127361 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-03-19
Onset:2021-03-23
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Decreased appetite, Fatigue, Respiration abnormal
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Omeprazole, Warfarin, Lipitor, Asprin, Baclofen, Vitamin D3,
Current Illness:
Preexisting Conditions:
Allergies: Metformin, Spiriva Respimat, Clindamycin, Lantus, Amoxicillin,
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death on 3/23/2021 at 9 AM. Home Health Nurse who gave immunization on 3/19/21 verbalized pt was fine after injection, stayed in home for 1 hour after injection was given. Wife verbalized pt was very tired the following day and through out the weekend. Pt stopped eating one day prior to death. Respirations changed on the morning of 3/23/2021 and wife called EMS, pt died at home.


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