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This is VAERS ID 1241401

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1241401
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: N/A
CDC 'Split Type':

Write-up: DEATH Narrative: Patient died after COVID vaccine dose #1. 01/14 COVID vaccine dose #1 04/13 pt died Patient with advanced ALS, progressive respiratory difficulty and passed away while on hospice. Vaccine did not likely contribute to the patient''s death, but was due to advanced ALS. Patient was not hospitalized prior to vaccine or immediately after vaccine. No adverse event following vaccine. No previous COVID diagnosis known.


Changed on 5/7/2021

VAERS ID: 1241401 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: N/A
CDC 'Split Type':

Write-up: DEATH Narrative: Patient died after COVID vaccine dose #1. 01/14 COVID vaccine dose #1 04/13 pt died Patient with advanced ALS, progressive respiratory difficulty and passed away while on hospice. Vaccine did not likely contribute to the patient''s death, but was due to advanced ALS. Patient was not hospitalized prior to vaccine or immediately after vaccine. No adverse event following vaccine. No previous COVID diagnosis known.


Changed on 5/14/2021

VAERS ID: 1241401 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-14
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Respiratory disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: N/A
CDC 'Split Type':

Write-up: DEATH Narrative: Patient died after COVID vaccine dose #1. 01/14 COVID vaccine dose #1 04/13 pt died Patient with advanced ALS, progressive respiratory difficulty and passed away while on hospice. Vaccine did not likely contribute to the patient''s death, but was due to advanced ALS. Patient was not hospitalized prior to vaccine or immediately after vaccine. No adverse event following vaccine. No previous COVID diagnosis known.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1241401&WAYBACKHISTORY=ON


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