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This is VAERS ID 1349711

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1349711
VAERS Form:1
Age:77.0
Sex:Male
Location:Tennessee
Vaccinated:2020-12-22
Onset:2021-01-07
Submitted:2021-01-11
Entered:2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD039K20A / 2 RA / -

Administered by: Other      Purchased by: Other
Symptoms: Cardio-respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-07
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':

Write-up: Symptoms: & cardiopulmonary arrest Treatment: EPINEPHRINE 8 MG Unknown during code

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1349711&WAYBACKHISTORY=ON

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