National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1221176

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221176
VAERS Form:2
Age:49.0
Sex:Unknown
Location:Oregon
Vaccinated:2021-03-30
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (he died) in a 49-year-old patient of an unknown gender 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 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on 03-Apr-2021 The patient died on 03-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were reported. No treatment medications were reported. Action taken with mRNA-1273 in response to the event was not applicable. Very limited information regarding this event has been provided at this time. Further information has been requested; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1221176 Before After
VAERS Form:2
Age:49.0
Sex:Unknown
Location:Oregon
Vaccinated:2021-03-30
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (he died) in a 49-year-old patient of an unknown gender 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 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on 03-Apr-2021 The patient died on 03-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were reported. No treatment medications were reported. Action taken with mRNA-1273 in response to the event was not applicable. Very limited information regarding this event has been provided at this time. Further information has been requested; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1221176 Before After
VAERS Form:2
Age:49.0
Sex:Unknown
Location:Oregon
Vaccinated:2021-03-30
Onset:2021-04-03
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-03
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: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (he died) in a 49-year-old patient of an unknown gender 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 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on 03-Apr-2021 The patient died on 03-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were reported. No treatment medications were reported. Action taken with mRNA-1273 in response to the event was not applicable. Very limited information regarding this event has been provided at this time. Further information has been requested; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1221176&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166