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This is VAERS ID 1245400

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1245400
VAERS Form:2
Age:57.0
Sex:Male
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-14
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown      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: Medical History/Concurrent Conditions: No adverse event (Medical history was not reported)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 57-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (Medical history was not reported). On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 14-Apr-2021 The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided Concomitant product use was not provided by the reporter. No treatment information was provided. Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed. Action taken with mRNA-1273 in response to the event was not applicable.; Sender''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 1245400 Before After
VAERS Form:2
Age:57.0
Sex:Male
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-14
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown      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: Medical History/Concurrent Conditions: No adverse event (Medical history was not reported)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 57-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (Medical history was not reported). On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 14-Apr-2021 The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided Concomitant product use was not provided by the reporter. No treatment information was provided. Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed. Action taken with mRNA-1273 in response to the event was not applicable.; Sender''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/14/2021

VAERS ID: 1245400 Before After
VAERS Form:2
Age:57.0
Sex:Male
Location:Texas
Vaccinated:0000-00-00
Onset:2021-04-14
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown      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: Medical History/Concurrent Conditions: No adverse event (Medical history was not reported)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 57-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (Medical history was not reported). On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 14-Apr-2021 The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided Concomitant product use was not provided by the reporter. No treatment information was provided. Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed. Action taken with mRNA-1273 in response to the event was not applicable.; Sender''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed.; Reported Cause(s) of Death: Unknown cause of death

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