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This is VAERS ID 1284730

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1284730
VAERS Form:2
Age:68.0
Sex:Male
Location:Florida
Vaccinated:2021-03-18
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / 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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 28-Apr-2021 and was forwarded to Moderna on 28-Apr-2021. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 68-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On 18-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No treatment information was provided. No concomitant medication was provided.; Sender''s Comments: This is a 68-year-old, male patient who received mRNA-1273 vaccine (batch no. unknown) who died, on an unknown date after receiving first dose of vaccine. No medical history or conmeds were provided. Existing comorbidities probably could have been the causative factor in his death. Very limited information has been reported at this time. Further information is expected.; Reported Cause(s) of Death: unknown cause of death


Changed on 5/14/2021

VAERS ID: 1284730 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Florida
Vaccinated:2021-03-18
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / 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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Death; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 28-Apr-2021 and was forwarded to Moderna on 28-Apr-2021. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 68-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On 18-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No treatment information was provided. No concomitant medication was provided.; Sender''s Comments: This is a 68-year-old, male patient who received mRNA-1273 vaccine (batch no. unknown) who died, on an unknown date after receiving first dose of vaccine. No medical history or conmeds were provided. Existing comorbidities probably could have been the causative factor in his death. Very limited information has been reported at this time. Further information is expected.; Reported Cause(s) of Death: unknown cause of death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1284730&WAYBACKHISTORY=ON

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