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This is VAERS ID 1236413

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1236413
VAERS Form:2
Age:70.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-11
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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 hospitalized in 02/2021 at facility for unknown reason until his passing on 3/7/2021. He had dx of HCV in 01/2021 that was cured but left him with cirrhosis s/p TIPS procedure. Was not liver transplant candidate due to home O2 needs. Other major comorbidities include COPD and diabetes.


Changed on 5/7/2021

VAERS ID: 1236413 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-11
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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 hospitalized in 02/2021 at facility for unknown reason until his passing on 3/7/2021. He had dx of HCV in 01/2021 that was cured but left him with cirrhosis s/p TIPS procedure. Was not liver transplant candidate due to home O2 needs. Other major comorbidities include COPD and diabetes.


Changed on 5/14/2021

VAERS ID: 1236413 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-11
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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 hospitalized in 02/2021 at facility for unknown reason until his passing on 3/7/2021. He had dx of HCV in 01/2021 that was cured but left him with cirrhosis s/p TIPS procedure. Was not liver transplant candidate due to home O2 needs. Other major comorbidities include COPD and diabetes.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1236413&WAYBACKHISTORY=ON

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