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This is VAERS ID 1180189

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1180189
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-23
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: A-Fib, hyperlipidemia, hypertension, pacemaker, kidney stones, Stroke, wound cellulitis, CAD, COPD/asthma, BPH, Gerd
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Hospitalization within 30 days of vaccination. Death within 60 days of vaccination


Changed on 5/7/2021

VAERS ID: 1180189 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-23
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: A-Fib, hyperlipidemia, hypertension, pacemaker, kidney stones, Stroke, wound cellulitis, CAD, COPD/asthma, BPH, Gerd
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Hospitalization within 30 days of vaccination. Death within 60 days of vaccination


Changed on 5/14/2021

VAERS ID: 1180189 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-23
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: A-Fib, hyperlipidemia, hypertension, pacemaker, kidney stones, Stroke, wound cellulitis, CAD, COPD/asthma, BPH, Gerd
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Hospitalization within 30 days of vaccination. Death within 60 days of vaccination

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1180189&WAYBACKHISTORY=ON

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