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This is VAERS ID 1237069

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1237069
VAERS Form:2
Age:65.0
Sex:Female
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-04-02
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure, Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, but did report use of blood thinner during vaccination visit.
Current Illness: None - per telephone interview with spouse
Preexisting Conditions: Unknown - none reported at vaccination visit
Allergies: NKA
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Spouse reported that patient was taken to The Hospital after unresponsive in the home on 4/2/2021. States was told that cause of death was heart failure.


Changed on 5/7/2021

VAERS ID: 1237069 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-04-02
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure, Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, but did report use of blood thinner during vaccination visit.
Current Illness: None - per telephone interview with spouse
Preexisting Conditions: Unknown - none reported at vaccination visit
Allergies: NKA NKA
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Spouse reported that patient was taken to The Hospital after unresponsive in the home on 4/2/2021. States was told that cause of death was heart failure.


Changed on 5/14/2021

VAERS ID: 1237069 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Kentucky
Vaccinated:2021-03-18
Onset:2021-04-02
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure, Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-02
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, but did report use of blood thinner during vaccination visit.
Current Illness: None - per telephone interview with spouse
Preexisting Conditions: Unknown - none reported at vaccination visit
Allergies: NKA NKA
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Spouse reported that patient was taken to The Hospital after unresponsive in the home on 4/2/2021. States was told that cause of death was heart failure.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1237069&WAYBACKHISTORY=ON


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