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This is VAERS ID 1220532

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1220532
VAERS Form:2
Age:77.0
Sex:Male
Location:Oregon
Vaccinated:2021-03-14
Onset:2021-03-31
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-31
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: penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.


Changed on 5/7/2021

VAERS ID: 1220532 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Oregon
Vaccinated:2021-03-14
Onset:2021-03-31
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-31
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: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.


Changed on 5/14/2021

VAERS ID: 1220532 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Oregon
Vaccinated:2021-03-14
Onset:2021-03-31
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-31
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: penicillin penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.

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