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This is VAERS ID 1243596

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1243596
VAERS Form:2
Age:65.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-24
Onset:2021-04-07
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Called to verify coming in for second dose on 4/21/21, family member confirmed death a few weeks ago (a few weeks after first covid dose). Cause of death unknown


Changed on 5/7/2021

VAERS ID: 1243596 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-24
Onset:2021-04-07
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Called to verify coming in for second dose on 4/21/21, family member confirmed death a few weeks ago (a few weeks after first covid dose). Cause of death unknown


Changed on 5/14/2021

VAERS ID: 1243596 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Minnesota
Vaccinated:2021-03-24
Onset:2021-04-07
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Called to verify coming in for second dose on 4/21/21, family member confirmed death a few weeks ago (a few weeks after first covid dose). Cause of death unknown

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1243596&WAYBACKHISTORY=ON


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