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This is VAERS ID 1219000

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1219000
VAERS Form:2
Age:93.0
Sex:Female
Location:Unknown
Vaccinated:2021-01-11
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-06
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: acetaminophen, ferrous sulfate, folic acid
Current Illness:
Preexisting Conditions: HTN, DM, right BKA, CVA, CAD
Allergies: penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and verbally responsive in usual state of health on 1/11/2021 received Moderna vaccination dose 1. Patient seemed stable until 2/6/21. Then on 2/6/21, patient was noted with slight elevated temp of 99.2, pulse 100, spo2 94%RA at 2:15am. By 5:20am, patient was pronounced dead.


Changed on 5/7/2021

VAERS ID: 1219000 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Unknown
Vaccinated:2021-01-11
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-06
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: acetaminophen, ferrous sulfate, folic acid
Current Illness:
Preexisting Conditions: HTN, DM, right BKA, CVA, CAD
Allergies: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and verbally responsive in usual state of health on 1/11/2021 received Moderna vaccination dose 1. Patient seemed stable until 2/6/21. Then on 2/6/21, patient was noted with slight elevated temp of 99.2, pulse 100, spo2 94%RA at 2:15am. By 5:20am, patient was pronounced dead.


Changed on 5/14/2021

VAERS ID: 1219000 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Unknown
Vaccinated:2021-01-11
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-06
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: acetaminophen, ferrous sulfate, folic acid
Current Illness:
Preexisting Conditions: HTN, DM, right BKA, CVA, CAD
Allergies: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was alert and verbally responsive in usual state of health on 1/11/2021 received Moderna vaccination dose 1. Patient seemed stable until 2/6/21. Then on 2/6/21, patient was noted with slight elevated temp of 99.2, pulse 100, spo2 94%RA at 2:15am. By 5:20am, patient was pronounced dead.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1219000&WAYBACKHISTORY=ON

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