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This is VAERS ID 1270366

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1270366
VAERS Form:2
Age:37.0
Sex:Male
Location:West Virginia
Vaccinated:2021-04-19
Onset:2021-04-24
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Wellbutrin
Current Illness:
Preexisting Conditions: Anxiety and depression
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: cardiac arrest 5 days post vaccination.


Changed on 5/7/2021

VAERS ID: 1270366 Before After
VAERS Form:2
Age:37.0
Sex:Male
Location:West Virginia
Vaccinated:2021-04-19
Onset:2021-04-24
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Wellbutrin
Current Illness:
Preexisting Conditions: Anxiety and depression
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: cardiac arrest 5 days post vaccination.


Changed on 5/14/2021

VAERS ID: 1270366 Before After
VAERS Form:2
Age:37.0
Sex:Male
Location:West Virginia
Vaccinated:2021-04-19
Onset:2021-04-24
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Wellbutrin
Current Illness:
Preexisting Conditions: Anxiety and depression
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: cardiac arrest 5 days post vaccination.

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