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This is VAERS ID 1156450

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1156450
VAERS Form:2
Age:96.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Feeling cold, Autopsy, Tryptase

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Gabapentin, atorvastatin, metoprolol, losartan potassium, phenazopyridine, triamcinolone, diclofenac, fluticasone propionate nasal spray USP
Current Illness:
Preexisting Conditions: hypertension, hyperlipidemia, dysnea on exertion, ischemic heart disease, coronary artery atherosclerosis
Allergies: none reported
Diagnostic Lab Data: A full autopsy was performed and completed on February 19, 2021. The report notes that there were no pathological findings related to the vaccine. A serum tryptase showed 3.7 ng/ml.
CDC 'Split Type':

Write-up: Patient received his second dose of the COVID-19 vaccine on February 17, 2021. Per family, he complained of feeling chilly and cold. He was found deceased in the early morning on February 18, 2021.


Changed on 5/7/2021

VAERS ID: 1156450 Before After
VAERS Form:2
Age:96.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Feeling cold, Autopsy, Tryptase

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Gabapentin, atorvastatin, metoprolol, losartan potassium, phenazopyridine, triamcinolone, diclofenac, fluticasone propionate nasal spray USP
Current Illness:
Preexisting Conditions: hypertension, hyperlipidemia, dysnea on exertion, ischemic heart disease, coronary artery atherosclerosis
Allergies: none reported reported
Diagnostic Lab Data: A full autopsy was performed and completed on February 19, 2021. The report notes that there were no pathological findings related to the vaccine. A serum tryptase showed 3.7 ng/ml.
CDC 'Split Type':

Write-up: Patient received his second dose of the COVID-19 vaccine on February 17, 2021. Per family, he complained of feeling chilly and cold. He was found deceased in the early morning on February 18, 2021.


Changed on 5/14/2021

VAERS ID: 1156450 Before After
VAERS Form:2
Age:96.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Feeling cold, Autopsy, Tryptase

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Gabapentin, atorvastatin, metoprolol, losartan potassium, phenazopyridine, triamcinolone, diclofenac, fluticasone propionate nasal spray USP
Current Illness:
Preexisting Conditions: hypertension, hyperlipidemia, dysnea on exertion, ischemic heart disease, coronary artery atherosclerosis
Allergies: none reported reported
Diagnostic Lab Data: A full autopsy was performed and completed on February 19, 2021. The report notes that there were no pathological findings related to the vaccine. A serum tryptase showed 3.7 ng/ml.
CDC 'Split Type':

Write-up: Patient received his second dose of the COVID-19 vaccine on February 17, 2021. Per family, he complained of feeling chilly and cold. He was found deceased in the early morning on February 18, 2021.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1156450&WAYBACKHISTORY=ON

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