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This is VAERS ID 1241383

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History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1241383
VAERS Form:2
Age:81.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-25
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Food refusal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
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: 80 yr old metastatic lung cancer, had stopped eating, still wanted vaccine, Died on hospice service. no vaccine complications reported.


Changed on 5/14/2021

VAERS ID: 1241383 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Unknown
Vaccinated:2021-02-25
Onset:2021-03-04
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Food refusal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-04
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: 80 yr old metastatic lung cancer, had stopped eating, still wanted vaccine, Died on hospice service. no vaccine complications reported.

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