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This is VAERS ID 1222837

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1222837
VAERS Form:2
Age:76.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-25
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pyrexia, Urinary tract infection, Cardiopulmonary failure, Secretion discharge

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: Levetiracetam 500 mg, Depakote 250 mg, Lantus
Current Illness: None reported
Preexisting Conditions: Diabetes, Seizures, Aggressiveness
Allergies: None reported
Diagnostic Lab Data: None reported
CDC 'Split Type': PR-106-21

Write-up: On 3/25/2021 POC alleges that the resident begin to develop fever and urine infection. He was transferred to the hospital on 3/26/2021 where he had white secretions in his mouth. On 3/28/2021 he died in the hospital from respiratory cardio failure.


Changed on 5/7/2021

VAERS ID: 1222837 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-25
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pyrexia, Urinary tract infection, Cardiopulmonary failure, Secretion discharge

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: Levetiracetam 500 mg, Depakote 250 mg, Lantus
Current Illness: None reported
Preexisting Conditions: Diabetes, Seizures, Aggressiveness
Allergies: None reported reported
Diagnostic Lab Data: None reported
CDC 'Split Type': PR-106-21

Write-up: On 3/25/2021 POC alleges that the resident begin to develop fever and urine infection. He was transferred to the hospital on 3/26/2021 where he had white secretions in his mouth. On 3/28/2021 he died in the hospital from respiratory cardio failure.


Changed on 5/14/2021

VAERS ID: 1222837 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-03-03
Onset:2021-03-25
Submitted:0000-00-00
Entered:2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pyrexia, Urinary tract infection, Cardiopulmonary failure, Secretion discharge

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-28
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: Levetiracetam 500 mg, Depakote 250 mg, Lantus
Current Illness: None reported
Preexisting Conditions: Diabetes, Seizures, Aggressiveness
Allergies: None reported reported
Diagnostic Lab Data: None reported
CDC 'Split Type': PR-106-21

Write-up: On 3/25/2021 POC alleges that the resident begin to develop fever and urine infection. He was transferred to the hospital on 3/26/2021 where he had white secretions in his mouth. On 3/28/2021 he died in the hospital from respiratory cardio failure.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1222837&WAYBACKHISTORY=ON

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