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This is VAERS ID 1221166

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221166
VAERS Form:2
Age:39.0
Sex:Female
Location:Indiana
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: needed kidney and/or bladder transplant; within 30 hs after second shot, she died; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (within 30 hs after second shot, she died) and TRANSPLANT (needed kidney and/or bladder transplant) in a 39-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced DEATH (within 30 hs after second shot, she died) (seriousness criterion death) and TRANSPLANT (needed kidney and/or bladder transplant) (seriousness criteria death, hospitalization and medically significant). The cause of death was not reported. It is unknown if an autopsy was performed. The reporter does not remember if this was from Pfizer or Moderna. Concomitant product us e was not provided. Treatment information was unknown. This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded. Reporter did not allow further contact; Reporter''s Comments: Th; Sender''s Comments: This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death


Changed on 5/7/2021

VAERS ID: 1221166 Before After
VAERS Form:2
Age:39.0
Sex:Female
Location:Indiana
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: needed kidney and/or bladder transplant; within 30 hs after second shot, she died; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (within 30 hs after second shot, she died) and TRANSPLANT (needed kidney and/or bladder transplant) in a 39-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced DEATH (within 30 hs after second shot, she died) (seriousness criterion death) and TRANSPLANT (needed kidney and/or bladder transplant) (seriousness criteria death, hospitalization and medically significant). The cause of death was not reported. It is unknown if an autopsy was performed. The reporter does not remember if this was from Pfizer or Moderna. Concomitant product us e was not provided. Treatment information was unknown. This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded. Reporter did not allow further contact; Reporter''s Comments: Th; Sender''s Comments: This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death


Changed on 5/14/2021

VAERS ID: 1221166 Before After
VAERS Form:2
Age:39.0
Sex:Female
Location:Indiana
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: needed kidney and/or bladder transplant; within 30 hs after second shot, she died; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (within 30 hs after second shot, she died) and TRANSPLANT (needed kidney and/or bladder transplant) in a 39-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced DEATH (within 30 hs after second shot, she died) (seriousness criterion death) and TRANSPLANT (needed kidney and/or bladder transplant) (seriousness criteria death, hospitalization and medically significant). The cause of death was not reported. It is unknown if an autopsy was performed. The reporter does not remember if this was from Pfizer or Moderna. Concomitant product us e was not provided. Treatment information was unknown. This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded. Reporter did not allow further contact; Reporter''s Comments: Th; Sender''s Comments: This case concerns death of a 30 year old female 30 minutes after the administration of the mRNA-1273 vaccine. Patient is reported to have no underlying issue. Based on the current available information which includes a strong temporal association between the use of mRNA-1273 vaccine and onset of the reported events, causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death

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