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This is VAERS ID 1272138

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1272138
VAERS Form:2
Age:90.0
Sex:Male
Location:Alabama
Vaccinated:2021-02-08
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Chronic kidney disease

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: SEROQUEL, GABAPENTIN, RESTORIL, OXYBUTYNIN, LIPITOR, ARICEPT,
Current Illness:
Preexisting Conditions: CONGESTIVE HEART FAILURE, STAGE IV CKD, HTN, BPH, PERIPHERAL NEUROPATHY, HYPERLIPDEMIA, ANEMIA, INSOMNIA,
Allergies: IODINE
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PFIZER-BIONTECH COVID-19 VACCINE EUA. PATIENT RECEIVED FIRST DOSE OF VACCINE ON 2/8/21. PATIENT REPORTEDLY PASSED AWAY ON 2/13/21 AT 7AM IN NURSING FACILITY. Record of death states CHF as principle cause of death and Stage IV CKD as contributory cause of death.


Changed on 5/7/2021

VAERS ID: 1272138 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Alabama
Vaccinated:2021-02-08
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Chronic kidney disease

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: SEROQUEL, GABAPENTIN, RESTORIL, OXYBUTYNIN, LIPITOR, ARICEPT,
Current Illness:
Preexisting Conditions: CONGESTIVE HEART FAILURE, STAGE IV CKD, HTN, BPH, PERIPHERAL NEUROPATHY, HYPERLIPDEMIA, ANEMIA, INSOMNIA,
Allergies: IODINE IODINE
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PFIZER-BIONTECH COVID-19 VACCINE EUA. PATIENT RECEIVED FIRST DOSE OF VACCINE ON 2/8/21. PATIENT REPORTEDLY PASSED AWAY ON 2/13/21 AT 7AM IN NURSING FACILITY. Record of death states CHF as principle cause of death and Stage IV CKD as contributory cause of death.


Changed on 5/14/2021

VAERS ID: 1272138 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:Alabama
Vaccinated:2021-02-08
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Chronic kidney disease

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: SEROQUEL, GABAPENTIN, RESTORIL, OXYBUTYNIN, LIPITOR, ARICEPT,
Current Illness:
Preexisting Conditions: CONGESTIVE HEART FAILURE, STAGE IV CKD, HTN, BPH, PERIPHERAL NEUROPATHY, HYPERLIPDEMIA, ANEMIA, INSOMNIA,
Allergies: IODINE IODINE
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: PFIZER-BIONTECH COVID-19 VACCINE EUA. PATIENT RECEIVED FIRST DOSE OF VACCINE ON 2/8/21. PATIENT REPORTEDLY PASSED AWAY ON 2/13/21 AT 7AM IN NURSING FACILITY. Record of death states CHF as principle cause of death and Stage IV CKD as contributory cause of death.

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