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This is VAERS ID 1155633

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1155633
VAERS Form:2
Age:82.0
Sex:Male
Location:Massachusetts
Vaccinated:2021-03-30
Onset:2021-04-01
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-01
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: unkonwn
Current Illness: unknown
Preexisting Conditions: none
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: cardiac arrest/vfib arrest


Changed on 5/7/2021

VAERS ID: 1155633 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Massachusetts
Vaccinated:2021-03-30
Onset:2021-04-01
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-01
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: unkonwn
Current Illness: unknown
Preexisting Conditions: none
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: cardiac arrest/vfib arrest

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1155633&WAYBACKHISTORY=ON


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