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This is VAERS ID 1157033

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1157033
VAERS Form:2
Age:67.0
Sex:Male
Location:California
Vaccinated:2021-03-30
Onset:2021-03-30
Submitted:0000-00-00
Entered:2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 2 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Nausea, Unresponsive to stimuli, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-31
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:
Current Illness:
Preexisting Conditions: ESRD, Type II DM with diabetic CKD, Long term use of insulin, Iron deficiency anemia, unspecified, Anemia in CKD, unspecified protein-calorie malnutrition, Other disorders of phosphorus metabolism, Unspecified amyloidosis, Blindness both eyes, Hypertensive CKD with stage 5 CKD, renal osteodystrophy, secondary hyperparathyroidism of renal origin, dependence on renal dialysis, renal osteodystrophy
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Per family patient reported c/o nausea and vomiting at home post treatment on 3/30/2021, he went to bed and was found unresponsive on 3/31, EMS was contacted and pronounced deceased at home on 3/31/2021. (exact time unknown).

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1157033&WAYBACKHISTORY=ON


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