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This is VAERS ID 1364724

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1364724
VAERS Form:2
Age:85.0
Sex:Female
Location:Tennessee
Vaccinated:2021-04-09
Onset:2021-05-18
Submitted:0000-00-00
Entered:2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Dyspnoea, Headache, Nausea, Vomiting, COVID-19, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-19
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Htn, GERD, Type 2 DM, COPD, ESRD, CHF, Afib
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Patient received second COVId 19 vaccine on 4/9/21 @ Health Department. Was admitted to hospital on 5/18/2021 with SOB, Nausea, Vomiting, and Headache. Diagnosed with COVID 19 infection and COVID 19 Pneumonia. Patient expired on 5/19/2021 at hospital.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1364724&WAYBACKHISTORY=ON

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