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This is VAERS ID 1154142

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1154142
VAERS Form:2
Age:77.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-27
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
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: cardia arrest Narrative: 76 yo with CAD, carotid artery stenosis, abdominal aortic aneurism, history of MI, DM. Patient was given both COVID vaccinations with the 2nd and most recent on 2/27. On 3/20, patient was admitted to an outside local emergency room with cardiac arrest and passed away at the facility. They were unsure if this had anything to do with his covid vaccinations but thought we should at least report it.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1154142&WAYBACKHISTORY=ON


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