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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1365754



Case Details

VAERS ID: 1365754 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-05-27
Onset:2021-06-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033B21A / 2 LL / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fatigue
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PT''S wife reported to the pharmacy that he was very tired after the vaccine on thursday and friday, he did not wake up on saturday, he passed away.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1365754

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