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This is VAERS ID 1365932

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1365932
VAERS Form:2
Age:49.0
Sex:Male
Location:California
Vaccinated:2021-04-13
Onset:2021-04-27
Submitted:0000-00-00
Entered:2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-27
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: Carvedilol 12.5 Mg Tab; Lisinopril 5 Mg tablet; K-Tab Cr 10 Tab; Furosemide 40 Mg Tab; Fluocinonide 0.05% Ointment; Sarna 0.5-0.5 % Lot Glax;
Current Illness:
Preexisting Conditions: Heart murmur Congestive heart failure Hypertension Obesity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient passed away on April 27, 2021, which was two weeks after receiving second dose of Moderna Covid-19 vaccine.

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