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This is VAERS ID 1187758

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1187758
VAERS Form:2
Age:89.0
Sex:Male
Location:New Jersey
Vaccinated:2021-04-09
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT WAS GIVEN JANSSEN COVID 19 VACCINE AT AROUND 12PM WHEN PATIENT WAS ACCOMPANIED BY HIS SON. HE WAS OBSERVED FOR 15 MINUTES AFTER THE VACCINATION AND LEFT PHARMACY WITHOUT ANY PROBLEM. PATIENT''S DAUGHTER CALLED AROUND 6PM AND REPORTED HER FATHER JUST DIED. SHE REPORTED HER FATHER ALL OF SUDDEN WAS SHAKING AND DIED RIGHT AFTER.


Changed on 5/7/2021

VAERS ID: 1187758 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:New Jersey
Vaccinated:2021-04-09
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT WAS GIVEN JANSSEN COVID 19 VACCINE AT AROUND 12PM WHEN PATIENT WAS ACCOMPANIED BY HIS SON. HE WAS OBSERVED FOR 15 MINUTES AFTER THE VACCINATION AND LEFT PHARMACY WITHOUT ANY PROBLEM. PATIENT''S DAUGHTER CALLED AROUND 6PM AND REPORTED HER FATHER JUST DIED. SHE REPORTED HER FATHER ALL OF SUDDEN WAS SHAKING AND DIED RIGHT AFTER.


Changed on 5/14/2021

VAERS ID: 1187758 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:New Jersey
Vaccinated:2021-04-09
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-09
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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN UNKNOWN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT WAS GIVEN JANSSEN COVID 19 VACCINE AT AROUND 12PM WHEN PATIENT WAS ACCOMPANIED BY HIS SON. HE WAS OBSERVED FOR 15 MINUTES AFTER THE VACCINATION AND LEFT PHARMACY WITHOUT ANY PROBLEM. PATIENT''S DAUGHTER CALLED AROUND 6PM AND REPORTED HER FATHER JUST DIED. SHE REPORTED HER FATHER ALL OF SUDDEN WAS SHAKING AND DIED RIGHT AFTER.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1187758&WAYBACKHISTORY=ON


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