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This is VAERS ID 1236419

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1236419
VAERS Form:2
Age:70.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-25
Onset:2021-02-09
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Somnolence, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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, that is a facility resident, received his Moderna covid vaccine #1 on 12/28/20. On 1/14/21 due a continued decline in status, he was changed to hospice care. On 1/25/21, he received covid #2. He was noted to have a decline in oral intake and increase in somnolence over a few weeks prior to his date of death on 2/9/21. No autopsy results available. 15 days from date of second vaccine to date of death.


Changed on 5/14/2021

VAERS ID: 1236419 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-25
Onset:2021-02-09
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Somnolence, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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, that is a facility resident, received his Moderna covid vaccine #1 on 12/28/20. On 1/14/21 due a continued decline in status, he was changed to hospice care. On 1/25/21, he received covid #2. He was noted to have a decline in oral intake and increase in somnolence over a few weeks prior to his date of death on 2/9/21. No autopsy results available. 15 days from date of second vaccine to date of death.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1236419&WAYBACKHISTORY=ON

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