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This is VAERS ID 1242858

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1242858
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-07
Onset:2021-04-19
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Respiratory distress, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-19
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: unnknown
Current Illness: unknown
Preexisting Conditions: chronic kidney disease, history of CVA
Allergies: penicillins, albuterol
Diagnostic Lab Data: COVID + 4/8/21
CDC 'Split Type':

Write-up: Patient contracted COVID 19 and subsequently expired from respiratory distress, following completion of the serious of two vaccination shots. She received her Moderna vaccinations on 1/7/21 and 2/4/21. I do not have access to the lot # info- would have to contact vaccination site to obtain


Changed on 5/7/2021

VAERS ID: 1242858 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-07
Onset:2021-04-19
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Respiratory distress, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-19
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: unnknown
Current Illness: unknown
Preexisting Conditions: chronic kidney disease, history of CVA
Allergies: penicillins, albuterol albuterol
Diagnostic Lab Data: COVID + 4/8/21
CDC 'Split Type':

Write-up: Patient contracted COVID 19 and subsequently expired from respiratory distress, following completion of the serious of two vaccination shots. She received her Moderna vaccinations on 1/7/21 and 2/4/21. I do not have access to the lot # info- would have to contact vaccination site to obtain


Changed on 5/14/2021

VAERS ID: 1242858 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-07
Onset:2021-04-19
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Respiratory distress, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-19
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: unnknown
Current Illness: unknown
Preexisting Conditions: chronic kidney disease, history of CVA
Allergies: penicillins, albuterol albuterol
Diagnostic Lab Data: COVID + 4/8/21
CDC 'Split Type':

Write-up: Patient contracted COVID 19 and subsequently expired from respiratory distress, following completion of the serious of two vaccination shots. She received her Moderna vaccinations on 1/7/21 and 2/4/21. I do not have access to the lot # info- would have to contact vaccination site to obtain

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1242858&WAYBACKHISTORY=ON


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