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This is VAERS ID 1171118

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1171118
VAERS Form:2
Age:73.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-02
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Resuscitation, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: None
Preexisting Conditions: Diabetes Mellitus Type 2
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received his first dose of Pfizer vaccine at around 10:15am on Friday April 2, 2021. His family reports he waited 15 minutes after vaccination and then proceeded home and reported no other issues. Patient collapsed at his home on Saturday April 3, 2021 around 11am. Family did CPR and called 911. Upon arrival of EMS they determined he was deceased and did not do anything further.


Changed on 5/7/2021

VAERS ID: 1171118 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-02
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Resuscitation, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: None
Preexisting Conditions: Diabetes Mellitus Type 2
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received his first dose of Pfizer vaccine at around 10:15am on Friday April 2, 2021. His family reports he waited 15 minutes after vaccination and then proceeded home and reported no other issues. Patient collapsed at his home on Saturday April 3, 2021 around 11am. Family did CPR and called 911. Upon arrival of EMS they determined he was deceased and did not do anything further.


Changed on 5/14/2021

VAERS ID: 1171118 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-02
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Resuscitation, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: None
Preexisting Conditions: Diabetes Mellitus Type 2
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received his first dose of Pfizer vaccine at around 10:15am on Friday April 2, 2021. His family reports he waited 15 minutes after vaccination and then proceeded home and reported no other issues. Patient collapsed at his home on Saturday April 3, 2021 around 11am. Family did CPR and called 911. Upon arrival of EMS they determined he was deceased and did not do anything further.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1171118&WAYBACKHISTORY=ON

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