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This is VAERS ID 1217813

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1217813
VAERS Form:2
Age:66.0
Sex:Male
Location:Michigan
Vaccinated:2021-04-13
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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; not currently ill per screening form
Preexisting Conditions: unknown
Allergies: none reported per screening form
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: deceased on 4/13/21


Changed on 5/7/2021

VAERS ID: 1217813 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Michigan
Vaccinated:2021-04-13
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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; not currently ill per screening form
Preexisting Conditions: unknown
Allergies: none reported per screening form form
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: deceased on 4/13/21


Changed on 5/14/2021

VAERS ID: 1217813 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Michigan
Vaccinated:2021-04-13
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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; not currently ill per screening form
Preexisting Conditions: unknown
Allergies: none reported per screening form form
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: deceased on 4/13/21

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1217813&WAYBACKHISTORY=ON

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