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This is VAERS ID 1130109

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1130109
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-20
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
CDC 'Split Type':

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient received his first dose of Pfizer vaccine on 1/20. Patient was on hospice and passed away at his home with family on 1/26. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


Changed on 5/7/2021

VAERS ID: 1130109 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-20
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
CDC 'Split Type':

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient received his first dose of Pfizer vaccine on 1/20. Patient was on hospice and passed away at his home with family on 1/26. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


Changed on 5/14/2021

VAERS ID: 1130109 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-20
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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:
CDC 'Split Type':

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient received his first dose of Pfizer vaccine on 1/20. Patient was on hospice and passed away at his home with family on 1/26. Cause of death not documented. No indication that death was related to COVID 19 vaccination.

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