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This is VAERS ID 1228974

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1228974
VAERS Form:2
Age:59.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-11
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

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: CLOPIDOGREL, FAMOTIDINE, HYDRALAZINE, MYCOPHENOLATE, CYCLOSPORINE, DIVALPROEX, LISINOPRIL, AMLODIPINE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT GOT FIRST DOSE OF MODERNA ON 03/11/21 AND PASSED AWAY ON 03/28/2021


Changed on 5/7/2021

VAERS ID: 1228974 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-11
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

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: CLOPIDOGREL, FAMOTIDINE, HYDRALAZINE, MYCOPHENOLATE, CYCLOSPORINE, DIVALPROEX, LISINOPRIL, AMLODIPINE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT GOT FIRST DOSE OF MODERNA ON 03/11/21 AND PASSED AWAY ON 03/28/2021


Changed on 5/14/2021

VAERS ID: 1228974 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-11
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

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: CLOPIDOGREL, FAMOTIDINE, HYDRALAZINE, MYCOPHENOLATE, CYCLOSPORINE, DIVALPROEX, LISINOPRIL, AMLODIPINE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PATIENT GOT FIRST DOSE OF MODERNA ON 03/11/21 AND PASSED AWAY ON 03/28/2021

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1228974&WAYBACKHISTORY=ON

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