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This is VAERS ID 1366906

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1366906
VAERS Form:2
Age:
Sex:Male
Location:Unknown
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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': USMODERNATX, INC.MOD20211

Write-up: Passed away; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Passed away) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. The patient''s wife reported that the patient passed away a few weeks after taking the Moderna vaccine. Concomitant medication and treatment information were not reported. Action taken with mRNA-1273 in response to the event was Not Applicable Company comment Very limited information regarding this event/s has been provided at this time. Further information has been requested. Reporter did not allow further contact; Sender''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death

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