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This is VAERS ID 1176896

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1176896
VAERS Form:2
Age:64.0
Sex:Male
Location:Montana
Vaccinated:2021-02-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: Losartan Potassium 50mg PO q day Claritin 10mg po q day Calcium 600mg PO q day CO Q 10 ASA 81mg q day
Current Illness:
Preexisting Conditions: History of Prostate Cancer
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of an apparent Cardiac Arrest.


Changed on 5/7/2021

VAERS ID: 1176896 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:Montana
Vaccinated:2021-02-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: Losartan Potassium 50mg PO q day Claritin 10mg po q day Calcium 600mg PO q day CO Q 10 ASA 81mg q day
Current Illness:
Preexisting Conditions: History of Prostate Cancer
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of an apparent Cardiac Arrest.


Changed on 5/14/2021

VAERS ID: 1176896 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:Montana
Vaccinated:2021-02-04
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: Losartan Potassium 50mg PO q day Claritin 10mg po q day Calcium 600mg PO q day CO Q 10 ASA 81mg q day
Current Illness:
Preexisting Conditions: History of Prostate Cancer
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died of an apparent Cardiac Arrest.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1176896&WAYBACKHISTORY=ON

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