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This is VAERS ID 1178531

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1178531
VAERS Form:2
Age:49.0
Sex:Male
Location:Colorado
Vaccinated:2021-04-04
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 AR / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-04
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 12 hours


Changed on 5/7/2021

VAERS ID: 1178531 Before After
VAERS Form:2
Age:49.0
Sex:Male
Location:Colorado
Vaccinated:2021-04-04
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 AR / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-04
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 12 hours


Changed on 5/14/2021

VAERS ID: 1178531 Before After
VAERS Form:2
Age:49.0
Sex:Male
Location:Colorado
Vaccinated:2021-04-04
Onset:2021-04-04
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 AR / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-04
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 12 hours

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1178531&WAYBACKHISTORY=ON

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