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This is VAERS ID 1269849

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1269849
VAERS Form:2
Age:82.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-16
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Delusion, Hallucination, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was transferred to behavioral health unit at an outside nursing home on 2/15/21 after hospitalization for psychiatric evaluation on 1/29/21 w/subsequent Law for erratic behavior w/ delusions/hallucinations. Patient passed away on 4/12/21 at an outside facility with details surrounding death unknown. PMH significant for CKD, AAA, PVD, anemia, CAD, Dm, HTN, COPD, advanced age.


Changed on 5/14/2021

VAERS ID: 1269849 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-16
Onset:2021-04-12
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Delusion, Hallucination, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was transferred to behavioral health unit at an outside nursing home on 2/15/21 after hospitalization for psychiatric evaluation on 1/29/21 w/subsequent Law for erratic behavior w/ delusions/hallucinations. Patient passed away on 4/12/21 at an outside facility with details surrounding death unknown. PMH significant for CKD, AAA, PVD, anemia, CAD, Dm, HTN, COPD, advanced age.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1269849&WAYBACKHISTORY=ON

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