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This is VAERS ID 1170447

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1170447
VAERS Form:2
Age:84.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Hepatic failure, Leukaemia, Malaise, Renal failure, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: First COVID 19 shot
Other Medications:
Current Illness: Leukemia, congestive heart failure
Preexisting Conditions: Leukemia, congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient fully recovered from natural SARS-COV-2 infection in early December 2020. Patient was doing quite well between mid December and mid January. Patient was hospitalized with congestive heart failure in late January 2021. Received first dose of Moderna COVID19 vaccine shortly before being discharged around February 1 (not sure of exact date). Patient was feeling well at that time. Patient became quite ill within 24 hours of Moderna COVID19 vaccine. Patient steadily worsened during February 2021. Was hospitalized in mid February (unsure of date) and diagnosed with kidney failure and liver disease. Congestive heart failure rapidly worsened and previously stable leukemia flared up. Patient was discharged from hospital February 19 and was placed in quarantine at Care Center. Patient was considered terminal and was to go into hospice care. Patient was administered second COVID19 vaccine on February 25, rapidly deteriorated, and died on March 1.


Changed on 5/7/2021

VAERS ID: 1170447 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Hepatic failure, Leukaemia, Malaise, Renal failure, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: First COVID 19 shot
Other Medications:
Current Illness: Leukemia, congestive heart failure
Preexisting Conditions: Leukemia, congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient fully recovered from natural SARS-COV-2 infection in early December 2020. Patient was doing quite well between mid December and mid January. Patient was hospitalized with congestive heart failure in late January 2021. Received first dose of Moderna COVID19 vaccine shortly before being discharged around February 1 (not sure of exact date). Patient was feeling well at that time. Patient became quite ill within 24 hours of Moderna COVID19 vaccine. Patient steadily worsened during February 2021. Was hospitalized in mid February (unsure of date) and diagnosed with kidney failure and liver disease. Congestive heart failure rapidly worsened and previously stable leukemia flared up. Patient was discharged from hospital February 19 and was placed in quarantine at Care Center. Patient was considered terminal and was to go into hospice care. Patient was administered second COVID19 vaccine on February 25, rapidly deteriorated, and died on March 1.


Changed on 5/14/2021

VAERS ID: 1170447 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-25
Onset:2021-02-25
Submitted:0000-00-00
Entered:2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Hepatic failure, Leukaemia, Malaise, Renal failure, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-01
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: First COVID 19 shot
Other Medications:
Current Illness: Leukemia, congestive heart failure
Preexisting Conditions: Leukemia, congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient fully recovered from natural SARS-COV-2 infection in early December 2020. Patient was doing quite well between mid December and mid January. Patient was hospitalized with congestive heart failure in late January 2021. Received first dose of Moderna COVID19 vaccine shortly before being discharged around February 1 (not sure of exact date). Patient was feeling well at that time. Patient became quite ill within 24 hours of Moderna COVID19 vaccine. Patient steadily worsened during February 2021. Was hospitalized in mid February (unsure of date) and diagnosed with kidney failure and liver disease. Congestive heart failure rapidly worsened and previously stable leukemia flared up. Patient was discharged from hospital February 19 and was placed in quarantine at Care Center. Patient was considered terminal and was to go into hospice care. Patient was administered second COVID19 vaccine on February 25, rapidly deteriorated, and died on March 1.

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