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This is VAERS ID 1230879

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1230879
VAERS Form:2
Age:68.0
Sex:Male
Location:California
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Lethargy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-10
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: None
Current Illness: None
Preexisting Conditions: slightly elevated blood pressure
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Heavy lethargy followed by death.


Changed on 5/7/2021

VAERS ID: 1230879 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:California
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Lethargy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-10
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: None
Current Illness: None
Preexisting Conditions: slightly elevated blood pressure
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Heavy lethargy followed by death.


Changed on 5/14/2021

VAERS ID: 1230879 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:California
Vaccinated:2021-03-01
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Lethargy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-10
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: None
Current Illness: None
Preexisting Conditions: slightly elevated blood pressure
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Heavy lethargy followed by death.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1230879&WAYBACKHISTORY=ON

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