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This is VAERS ID 1219667

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1219667
VAERS Form:2
Age:63.0
Sex:Male
Location:California
Vaccinated:2021-04-06
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 UN / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Computerised tomogram, Death, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Hydralazine, Furosemide, Warfarin, Potassium, Glipizide
Current Illness: none
Preexisting Conditions: Diabetic, Stage 4 Kidney Failure, Heart Disease, High Blood Pressure, Sleep Apnea.
Allergies: None
Diagnostic Lab Data: CT Scans
CDC 'Split Type':

Write-up: Patient had a Hemorrhagic stoke and passed away.


Changed on 5/7/2021

VAERS ID: 1219667 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:California
Vaccinated:2021-04-06
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 UN / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Computerised tomogram, Death, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Hydralazine, Furosemide, Warfarin, Potassium, Glipizide
Current Illness: none
Preexisting Conditions: Diabetic, Stage 4 Kidney Failure, Heart Disease, High Blood Pressure, Sleep Apnea.
Allergies: None None
Diagnostic Lab Data: CT Scans
CDC 'Split Type':

Write-up: Patient had a Hemorrhagic stoke and passed away.


Changed on 5/14/2021

VAERS ID: 1219667 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:California
Vaccinated:2021-04-06
Onset:2021-04-09
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 UN / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Computerised tomogram, Death, Haemorrhagic stroke

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Hydralazine, Furosemide, Warfarin, Potassium, Glipizide
Current Illness: none
Preexisting Conditions: Diabetic, Stage 4 Kidney Failure, Heart Disease, High Blood Pressure, Sleep Apnea.
Allergies: None None
Diagnostic Lab Data: CT Scans
CDC 'Split Type':

Write-up: Patient had a Hemorrhagic stoke and passed away.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1219667&WAYBACKHISTORY=ON

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