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This is VAERS ID 1236415

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1236415
VAERS Form:2
Age:44.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-25
Onset:2021-03-30
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-30
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 received Moderna covid vaccine #1 on 3/25/21. No notes entered after this time and date of death is recorded as 3/30/21. No scanned records. No autopsy results available. 5 days from date of vaccine to date of death.


Changed on 5/7/2021

VAERS ID: 1236415 Before After
VAERS Form:2
Age:44.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-25
Onset:2021-03-30
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-30
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 received Moderna covid vaccine #1 on 3/25/21. No notes entered after this time and date of death is recorded as 3/30/21. No scanned records. No autopsy results available. 5 days from date of vaccine to date of death.


Changed on 5/14/2021

VAERS ID: 1236415 Before After
VAERS Form:2
Age:44.0
Sex:Male
Location:Unknown
Vaccinated:2021-03-25
Onset:2021-03-30
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-30
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 received Moderna covid vaccine #1 on 3/25/21. No notes entered after this time and date of death is recorded as 3/30/21. No scanned records. No autopsy results available. 5 days from date of vaccine to date of death.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1236415&WAYBACKHISTORY=ON

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