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This is VAERS ID 1231112

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1231112
VAERS Form:2
Age:87.0
Sex:Female
Location:Florida
Vaccinated:2021-03-22
Onset:2021-03-24
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-15
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to the hospital approximately 2 days after receiving the Moderna vaccine. She was under Hospice care before receiving the vaccine.


Changed on 5/7/2021

VAERS ID: 1231112 Before After
VAERS Form:2
Age:87.0
Sex:Female
Location:Florida
Vaccinated:2021-03-22
Onset:2021-03-24
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-15
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to the hospital approximately 2 days after receiving the Moderna vaccine. She was under Hospice care before receiving the vaccine.


Changed on 5/14/2021

VAERS ID: 1231112 Before After
VAERS Form:2
Age:87.0
Sex:Female
Location:Florida
Vaccinated:2021-03-22
Onset:2021-03-24
Submitted:0000-00-00
Entered:2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-15
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to the hospital approximately 2 days after receiving the Moderna vaccine. She was under Hospice care before receiving the vaccine.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1231112&WAYBACKHISTORY=ON

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