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This is VAERS ID 1245392

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1245392
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Fatigue, Vaccination site pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: arm was really sore; felt tired; passed away / she was dead; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away / she was dead) in a 71-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired). The patient died on 13-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired) outcome was unknown. No treatment information was provided. No concomitant medications was provided. Reporter did not allow further contact; Reported Cause(s) of Death: unknown cause of death


Changed on 5/7/2021

VAERS ID: 1245392 Before After
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Fatigue, Vaccination site pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: arm was really sore; felt tired; passed away / she was dead; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away / she was dead) in a 71-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired). The patient died on 13-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired) outcome was unknown. No treatment information was provided. No concomitant medications was provided. Reporter did not allow further contact; Reported Cause(s) of Death: unknown cause of death


Changed on 5/14/2021

VAERS ID: 1245392 Before After
VAERS Form:2
Age:
Sex:Female
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Fatigue, Vaccination site pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: arm was really sore; felt tired; passed away / she was dead; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away / she was dead) in a 71-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired). The patient died on 13-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired) outcome was unknown. No treatment information was provided. No concomitant medications was provided. Reporter did not allow further contact; Reported Cause(s) of Death: unknown cause of death

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