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This is VAERS ID 1236785

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1236785
VAERS Form:2
Age:77.0
Sex:Male
Location:Ohio
Vaccinated:2021-04-16
Onset:2021-04-17
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Resuscitation, Unresponsive to stimuli, Vital functions abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-17
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: ASA, Tramadol, Eliquis, Proscar, Carvedilol, Atorvastatin,Tamsulosin, Colchicine, Fenofibrate, Thiamine, Lisinopril, Folic Acid, Glimepiride
Current Illness: cellulitis and abcesses of Lower extremeties. pressure ulcers
Preexisting Conditions: Type 2 DM, Essential HTN, BPH, CKD Stage 3, Hyperlipidemia Anemia, ASHD, Gout, Peripheral artery disease,Arterial stenosis, pacemaker ( inserted 1/27/2021), Atrial fibrillation recent with TEE cardioversion 3/31/2021, cellulitis and abcesses of the lower extremeties, pressure injuries-unstageable to bilateral heels and side of the foot., S/P PTA of the right peroneal artery (1/2021) , fall March 2021
Allergies: Oxycodone
Diagnostic Lab Data: N/A -
CDC 'Split Type':

Write-up: Resident found unresponsive and without vital signs the morning on April 17, 2021 at 6:35am. The nurse started CPR, called a code, 911 called, AED applied. Local EMS responded, took over the code. EMS had contact with the local hospital ER, code called at the facility. Resident expired.


Changed on 5/7/2021

VAERS ID: 1236785 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Ohio
Vaccinated:2021-04-16
Onset:2021-04-17
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Resuscitation, Unresponsive to stimuli, Vital functions abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-17
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: ASA, Tramadol, Eliquis, Proscar, Carvedilol, Atorvastatin,Tamsulosin, Colchicine, Fenofibrate, Thiamine, Lisinopril, Folic Acid, Glimepiride
Current Illness: cellulitis and abcesses of Lower extremeties. pressure ulcers
Preexisting Conditions: Type 2 DM, Essential HTN, BPH, CKD Stage 3, Hyperlipidemia Anemia, ASHD, Gout, Peripheral artery disease,Arterial stenosis, pacemaker ( inserted 1/27/2021), Atrial fibrillation recent with TEE cardioversion 3/31/2021, cellulitis and abcesses of the lower extremeties, pressure injuries-unstageable to bilateral heels and side of the foot., S/P PTA of the right peroneal artery (1/2021) , fall March 2021
Allergies: Oxycodone Oxycodone
Diagnostic Lab Data: N/A -
CDC 'Split Type':

Write-up: Resident found unresponsive and without vital signs the morning on April 17, 2021 at 6:35am. The nurse started CPR, called a code, 911 called, AED applied. Local EMS responded, took over the code. EMS had contact with the local hospital ER, code called at the facility. Resident expired.


Changed on 5/14/2021

VAERS ID: 1236785 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Ohio
Vaccinated:2021-04-16
Onset:2021-04-17
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Resuscitation, Unresponsive to stimuli, Vital functions abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-17
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: ASA, Tramadol, Eliquis, Proscar, Carvedilol, Atorvastatin,Tamsulosin, Colchicine, Fenofibrate, Thiamine, Lisinopril, Folic Acid, Glimepiride
Current Illness: cellulitis and abcesses of Lower extremeties. pressure ulcers
Preexisting Conditions: Type 2 DM, Essential HTN, BPH, CKD Stage 3, Hyperlipidemia Anemia, ASHD, Gout, Peripheral artery disease,Arterial stenosis, pacemaker ( inserted 1/27/2021), Atrial fibrillation recent with TEE cardioversion 3/31/2021, cellulitis and abcesses of the lower extremeties, pressure injuries-unstageable to bilateral heels and side of the foot., S/P PTA of the right peroneal artery (1/2021) , fall March 2021
Allergies: Oxycodone Oxycodone
Diagnostic Lab Data: N/A -
CDC 'Split Type':

Write-up: Resident found unresponsive and without vital signs the morning on April 17, 2021 at 6:35am. The nurse started CPR, called a code, 911 called, AED applied. Local EMS responded, took over the code. EMS had contact with the local hospital ER, code called at the facility. Resident expired.

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