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This is VAERS ID 1221106

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221106
VAERS Form:2
Age:
Sex:Male
Location:Tennessee
Vaccinated:2021-02-10
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Eleven days after receiving the dose, he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Eleven days after receiving the dose, he died) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 011L20A) for COVID-19 vaccination. The patient''s past medical history included COVID-19. On 10-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 21-Feb-2021 The patient died on 21-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Unknown Action taken with mRNA-1273 in response to the event was not applicable. Prior to the patient''s receiving his first dose of the Moderna Covid-19 vaccine series, wife reported that he was hospitalized for Covid-19 infection for three weeks. While hospitalized, he was treated for Covid-19 infection with medications unknown to her and was very sick on a ventilator in the ICU. He was then discharged to a rehab facility for several weeks and moved to a nursing home for additional rehab. Eleven days after receiving the dose, he died on 21 Feb 2021. He had been getting along well and working on coming home prior to receiving the first dose. Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Sender''s Comments: Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1221106 Before After
VAERS Form:2
Age:
Sex:Male
Location:Tennessee
Vaccinated:2021-02-10
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Eleven days after receiving the dose, he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Eleven days after receiving the dose, he died) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 011L20A) for COVID-19 vaccination. The patient''s past medical history included COVID-19. On 10-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 21-Feb-2021 The patient died on 21-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Unknown Action taken with mRNA-1273 in response to the event was not applicable. Prior to the patient''s receiving his first dose of the Moderna Covid-19 vaccine series, wife reported that he was hospitalized for Covid-19 infection for three weeks. While hospitalized, he was treated for Covid-19 infection with medications unknown to her and was very sick on a ventilator in the ICU. He was then discharged to a rehab facility for several weeks and moved to a nursing home for additional rehab. Eleven days after receiving the dose, he died on 21 Feb 2021. He had been getting along well and working on coming home prior to receiving the first dose. Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Sender''s Comments: Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1221106 Before After
VAERS Form:2
Age:
Sex:Male
Location:Tennessee
Vaccinated:2021-02-10
Onset:2021-02-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-21
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Eleven days after receiving the dose, he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Eleven days after receiving the dose, he died) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 011L20A) for COVID-19 vaccination. The patient''s past medical history included COVID-19. On 10-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 21-Feb-2021 The patient died on 21-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Unknown Action taken with mRNA-1273 in response to the event was not applicable. Prior to the patient''s receiving his first dose of the Moderna Covid-19 vaccine series, wife reported that he was hospitalized for Covid-19 infection for three weeks. While hospitalized, he was treated for Covid-19 infection with medications unknown to her and was very sick on a ventilator in the ICU. He was then discharged to a rehab facility for several weeks and moved to a nursing home for additional rehab. Eleven days after receiving the dose, he died on 21 Feb 2021. He had been getting along well and working on coming home prior to receiving the first dose. Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Sender''s Comments: Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded; Reported Cause(s) of Death: Unknown cause of death

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