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This is VAERS ID 1273868

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1273868
VAERS Form:2
Age:84.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-26
Onset:2021-04-28
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Malaise, Sudden death

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide, Amlodipine, Coreg, Benazepril, Lipitor, Amaryl, Actos, Metformin, Tylenol #3
Current Illness: None. Reports to neighbor of "feeling under the weather" sometime about 04/24/2021 to 4/27/2021.
Preexisting Conditions: Type 2 DM with retinopathy and neuropathy, HTN, BPH, DDD lumbar spine
Allergies: Ambien, Ativan, Cardura, Elavil, Darvocet (?)
Diagnostic Lab Data: Check with local Medical Examiner
CDC 'Split Type':

Write-up: Sudden death (Patient''s son should have access to COVID-19 vaccination card with lot numbers and location where vaccine was administered.)


Changed on 5/14/2021

VAERS ID: 1273868 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-26
Onset:2021-04-28
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Malaise, Sudden death

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide, Amlodipine, Coreg, Benazepril, Lipitor, Amaryl, Actos, Metformin, Tylenol #3
Current Illness: None. Reports to neighbor of "feeling under the weather" sometime about 04/24/2021 to 4/27/2021.
Preexisting Conditions: Type 2 DM with retinopathy and neuropathy, HTN, BPH, DDD lumbar spine
Allergies: Ambien, Ativan, Cardura, Elavil, Darvocet (?) (?)
Diagnostic Lab Data: Check with local Medical Examiner
CDC 'Split Type':

Write-up: Sudden death (Patient''s son should have access to COVID-19 vaccination card with lot numbers and location where vaccine was administered.)

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1273868&WAYBACKHISTORY=ON

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