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This is VAERS ID 1230283

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1230283
VAERS Form:2
Age:75.0
Sex:Male
Location:North Carolina
Vaccinated:2021-03-29
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Resuscitation, Acute cardiac event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: heart disease per EMS report
Allergies: none reported
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Reported to the vaccination clinic by county EMS: Pt expired at his home following a call to 911 for a cardiac event for which resuscitation efforts were unsuccessful. This occured on the same day as his last dose of the Moderna vaccine.


Changed on 5/7/2021

VAERS ID: 1230283 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:North Carolina
Vaccinated:2021-03-29
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Resuscitation, Acute cardiac event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: heart disease per EMS report
Allergies: none reported reported
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Reported to the vaccination clinic by county EMS: Pt expired at his home following a call to 911 for a cardiac event for which resuscitation efforts were unsuccessful. This occured on the same day as his last dose of the Moderna vaccine.


Changed on 5/14/2021

VAERS ID: 1230283 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:North Carolina
Vaccinated:2021-03-29
Onset:2021-03-29
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Resuscitation, Acute cardiac event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: heart disease per EMS report
Allergies: none reported reported
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Reported to the vaccination clinic by county EMS: Pt expired at his home following a call to 911 for a cardiac event for which resuscitation efforts were unsuccessful. This occured on the same day as his last dose of the Moderna vaccine.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1230283&WAYBACKHISTORY=ON

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