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This is VAERS ID 115054

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 115054
VAERS Form:
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1998-1999 / CONNAUGHT LABS 0975790 / - A / IM

Administered by: Public      Purchased by: Unknown
Symptoms: REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 12/8/2009

VAERS ID: 115054 Before After
VAERS Form:
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-20 1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUZONE 1998-1999 INFLUENZA (SEASONAL) (FLUZONE 98-99) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0975790 / - A / IM

Administered by: Public      Purchased by: Unknown Public
Symptoms: Unevaluable event, REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 8/31/2010

VAERS ID: 115054 Before After
VAERS Form:
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE 98-99) INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / - A / IM

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 7/7/2013

VAERS ID: 115054 Before After
VAERS Form:
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / - A / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / - A / IM

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 5/14/2017

VAERS ID: 115054 Before After
VAERS Form:
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / - A - / IM IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 9/14/2017

VAERS ID: 115054 Before After
VAERS Form:(blank) 1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / - UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 2/14/2018

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 6/14/2018

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 8/14/2018

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 9/14/2018

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 10/14/2018

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 12/24/2020

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

Changed on 12/30/2020

VAERS ID: 115054 Before After
VAERS Form:1
Age:83.0
Sex:Male
Location:Massachusetts
Vaccinated:1998-10-08
Onset:1998-10-08
Submitted:1998-10-14
Entered:1998-10-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 0975790 / UNK - / IM A

Administered by: Public      Purchased by: Public
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-10-08
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: ~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: NKDA or other allergies;
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': U199800624

Write-up: pt recv vax & approx 30min post vax pt collapsed @ home brought to hosp & pronounced DOA;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=115054&WAYBACKHISTORY=ON


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