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This is VAERS ID 1361525

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History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1361525
VAERS Form:2
Age:76.0
Sex:Male
Location:Florida
Vaccinated:2021-05-27
Onset:2021-05-28
Submitted:0000-00-00
Entered:2021-05-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-28
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: simvastatin; lisinopril
Current Illness: none known
Preexisting Conditions: COPD; high cholesterol; HTN
Allergies: pollen allergies; no other allergies known
Diagnostic Lab Data: Death
CDC 'Split Type':

Write-up: None known. However, died on 5/28/21 at 06:11

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