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This is VAERS ID 1180818

History of Changes from the VAERS Wayback Machine

First Appeared on 4/8/2021

VAERS ID: 1180818
VAERS Form:2
Age:69.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-03-19
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 RA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardiac arrest, Death, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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: Coronary Artery Disease with history of By-pass surgery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Recipient of vaccine is a family member (father) of employee of Hospital. Recipient was vaccinated with Dose 2 Pfizer Covid vaccine on 3/19/2021 and observed on-site for 15 minutes after vaccination with no apparent concerns. On 3/23/2021, his daughter (our employee) notified clinic that on 3/22/2021, recipient had died. 4/7/2021 his daughter (our employee) states the medical examiner indicated his autopsy showed evidence of cardiac arrest.


Changed on 5/7/2021

VAERS ID: 1180818 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-03-19
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 RA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardiac arrest, Death, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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: Coronary Artery Disease with history of By-pass surgery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Recipient of vaccine is a family member (father) of employee of Hospital. Recipient was vaccinated with Dose 2 Pfizer Covid vaccine on 3/19/2021 and observed on-site for 15 minutes after vaccination with no apparent concerns. On 3/23/2021, his daughter (our employee) notified clinic that on 3/22/2021, recipient had died. 4/7/2021 his daughter (our employee) states the medical examiner indicated his autopsy showed evidence of cardiac arrest.


Changed on 5/14/2021

VAERS ID: 1180818 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-03-19
Onset:2021-03-22
Submitted:0000-00-00
Entered:2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 RA / IM

Administered by: Work      Purchased by: ??
Symptoms: Cardiac arrest, Death, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-22
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: Coronary Artery Disease with history of By-pass surgery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Recipient of vaccine is a family member (father) of employee of Hospital. Recipient was vaccinated with Dose 2 Pfizer Covid vaccine on 3/19/2021 and observed on-site for 15 minutes after vaccination with no apparent concerns. On 3/23/2021, his daughter (our employee) notified clinic that on 3/22/2021, recipient had died. 4/7/2021 his daughter (our employee) states the medical examiner indicated his autopsy showed evidence of cardiac arrest.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1180818&WAYBACKHISTORY=ON

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