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This is VAERS ID 1198540

History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 1198540
VAERS Form:2
Age:21.0
Sex:Male
Location:California
Vaccinated:2021-04-01
Onset:2021-04-11
Submitted:0000-00-00
Entered:2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: School      Purchased by: ??
Symptoms: Death, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: none known
Current Illness: none known
Preexisting Conditions: none known
Allergies: reported none on medical screening
Diagnostic Lab Data: unknown what was done at hospital.
CDC 'Split Type':

Write-up: Unknown if the vaccine has any correlation to event. Patient was found unresponsive and not breathing on 4/11/21 @ approximately 3:45 PM outside on the grounds of the campus. A rented scoter was next to him. There was no sign of trauma. 9-1-1 was called and CPR initiated by passerby (there were no witnesses). He remained unresponsive and was intubated when the paramedics arrived. He was transported to hospital where he was pronounced dead.


Changed on 5/7/2021

VAERS ID: 1198540 Before After
VAERS Form:2
Age:21.0
Sex:Male
Location:California
Vaccinated:2021-04-01
Onset:2021-04-11
Submitted:0000-00-00
Entered:2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: School      Purchased by: ??
Symptoms: Death, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: none known
Current Illness: none known
Preexisting Conditions: none known
Allergies: reported none on medical screening screening
Diagnostic Lab Data: unknown what was done at hospital.
CDC 'Split Type':

Write-up: Unknown if the vaccine has any correlation to event. Patient was found unresponsive and not breathing on 4/11/21 @ approximately 3:45 PM outside on the grounds of the campus. A rented scoter was next to him. There was no sign of trauma. 9-1-1 was called and CPR initiated by passerby (there were no witnesses). He remained unresponsive and was intubated when the paramedics arrived. He was transported to hospital where he was pronounced dead.


Changed on 5/14/2021

VAERS ID: 1198540 Before After
VAERS Form:2
Age:21.0
Sex:Male
Location:California
Vaccinated:2021-04-01
Onset:2021-04-11
Submitted:0000-00-00
Entered:2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: School      Purchased by: ??
Symptoms: Death, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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: none known
Current Illness: none known
Preexisting Conditions: none known
Allergies: reported none on medical screening screening
Diagnostic Lab Data: unknown what was done at hospital.
CDC 'Split Type':

Write-up: Unknown if the vaccine has any correlation to event. Patient was found unresponsive and not breathing on 4/11/21 @ approximately 3:45 PM outside on the grounds of the campus. A rented scoter was next to him. There was no sign of trauma. 9-1-1 was called and CPR initiated by passerby (there were no witnesses). He remained unresponsive and was intubated when the paramedics arrived. He was transported to hospital where he was pronounced dead.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1198540&WAYBACKHISTORY=ON


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