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This is VAERS ID 1243791

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1243791
VAERS Form:2
Age:21.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-10
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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: Per family, Xarelto
Current Illness: None communicated at this time to this office
Preexisting Conditions: History of clotting disorder at age 16 with Xarelto treatment and hospitalization
Allergies: None communicated to this office
Diagnostic Lab Data: None known at this time.
CDC 'Split Type':

Write-up: Per the father, the deceased received his first shot of Moderna vaccine on Saturday, 4/10/2021 at a local church. He did not work on 4/11/2021. Worked on 4/12/2021. The deceased was found dead at 6:43 p.m. at his home.


Changed on 5/7/2021

VAERS ID: 1243791 Before After
VAERS Form:2
Age:21.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-10
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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: Per family, Xarelto
Current Illness: None communicated at this time to this office
Preexisting Conditions: History of clotting disorder at age 16 with Xarelto treatment and hospitalization
Allergies: None communicated to this office office
Diagnostic Lab Data: None known at this time.
CDC 'Split Type':

Write-up: Per the father, the deceased received his first shot of Moderna vaccine on Saturday, 4/10/2021 at a local church. He did not work on 4/11/2021. Worked on 4/12/2021. The deceased was found dead at 6:43 p.m. at his home.


Changed on 5/14/2021

VAERS ID: 1243791 Before After
VAERS Form:2
Age:21.0
Sex:Male
Location:Virginia
Vaccinated:2021-04-10
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
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: Per family, Xarelto
Current Illness: None communicated at this time to this office
Preexisting Conditions: History of clotting disorder at age 16 with Xarelto treatment and hospitalization
Allergies: None communicated to this office office
Diagnostic Lab Data: None known at this time.
CDC 'Split Type':

Write-up: Per the father, the deceased received his first shot of Moderna vaccine on Saturday, 4/10/2021 at a local church. He did not work on 4/11/2021. Worked on 4/12/2021. The deceased was found dead at 6:43 p.m. at his home.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1243791&WAYBACKHISTORY=ON


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