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This is VAERS ID 1222565

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1222565
VAERS Form:2
Age:93.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Dysphagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Lisinopril, Vitamin D3,Vitamina c Donepezil, Trazadone, Metoprolol
Current Illness: None reported
Preexisting Conditions: Advanced Stage Alzheimer''s, Hypertensive, Hospice
Allergies: None reported
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: Resident was in Hospice and began to stops wallowing. Respiratory cardiac arrest


Changed on 5/7/2021

VAERS ID: 1222565 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Dysphagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Lisinopril, Vitamin D3,Vitamina c Donepezil, Trazadone, Metoprolol
Current Illness: None reported
Preexisting Conditions: Advanced Stage Alzheimer''s, Hypertensive, Hospice
Allergies: None reported reported
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: Resident was in Hospice and began to stops wallowing. Respiratory cardiac arrest


Changed on 5/14/2021

VAERS ID: 1222565 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Dysphagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Lisinopril, Vitamin D3,Vitamina c Donepezil, Trazadone, Metoprolol
Current Illness: None reported
Preexisting Conditions: Advanced Stage Alzheimer''s, Hypertensive, Hospice
Allergies: None reported reported
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: Resident was in Hospice and began to stops wallowing. Respiratory cardiac arrest

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1222565&WAYBACKHISTORY=ON

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