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This is VAERS ID 1179974

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1179974
VAERS Form:2
Age:73.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Pneumonia, Respiratory failure, COVID-19, SARS-CoV-2 test positive

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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: pt diagnosed with COVID on 3-29-21, was hospitalized, developed pneumonia and respiratory failure and expired on 4-6-21
Preexisting Conditions: HTN/GERD
Allergies: nkda
Diagnostic Lab Data: COVID + PCR on 3-29-21
CDC 'Split Type':

Write-up: pt was diagnosed with covid on 3-29-21 , hospitalized for pneumonia and respiratory failure and expired on 4-6-21 at Hospital


Changed on 5/7/2021

VAERS ID: 1179974 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Pneumonia, Respiratory failure, COVID-19, SARS-CoV-2 test positive

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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: pt diagnosed with COVID on 3-29-21, was hospitalized, developed pneumonia and respiratory failure and expired on 4-6-21
Preexisting Conditions: HTN/GERD
Allergies: nkda nkda
Diagnostic Lab Data: COVID + PCR on 3-29-21
CDC 'Split Type':

Write-up: pt was diagnosed with covid on 3-29-21 , hospitalized for pneumonia and respiratory failure and expired on 4-6-21 at Hospital


Changed on 5/14/2021

VAERS ID: 1179974 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Pneumonia, Respiratory failure, COVID-19, SARS-CoV-2 test positive

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? Yes, days: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: pt diagnosed with COVID on 3-29-21, was hospitalized, developed pneumonia and respiratory failure and expired on 4-6-21
Preexisting Conditions: HTN/GERD
Allergies: nkda nkda
Diagnostic Lab Data: COVID + PCR on 3-29-21
CDC 'Split Type':

Write-up: pt was diagnosed with covid on 3-29-21 , hospitalized for pneumonia and respiratory failure and expired on 4-6-21 at Hospital

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1179974&WAYBACKHISTORY=ON

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