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This is VAERS ID 1228013

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1228013
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-01
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death. Narrative: Patient was not previously COVID positive and did not have any predisposing factors (PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 74 but no cause of death listed or notes of recent care. Patient was hospitalized with chest pain in 6/2020 and has h/o of severe multivessel CAD, HFrEF, and polysubstance abuse.


Changed on 5/7/2021

VAERS ID: 1228013 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-01
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death. Narrative: Patient was not previously COVID positive and did not have any predisposing factors (PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 74 but no cause of death listed or notes of recent care. Patient was hospitalized with chest pain in 6/2020 and has h/o of severe multivessel CAD, HFrEF, and polysubstance abuse.


Changed on 5/14/2021

VAERS ID: 1228013 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-01
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Military      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death. Narrative: Patient was not previously COVID positive and did not have any predisposing factors (PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 74 but no cause of death listed or notes of recent care. Patient was hospitalized with chest pain in 6/2020 and has h/o of severe multivessel CAD, HFrEF, and polysubstance abuse.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1228013&WAYBACKHISTORY=ON

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