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This is VAERS ID 1371720

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1371720
VAERS Form:2
Age:52.0
Sex:Male
Location:Illinois
Vaccinated:2021-05-05
Onset:2021-05-14
Submitted:0000-00-00
Entered:2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009C21A / 1 - / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-14
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: Atorvastatin, Hyzaar, Amlodipine
Current Illness: None
Preexisting Conditions: LBBB, Obesity, HTN, Hyperlipidemia, Prediabetes
Allergies: None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Death, cardiac arrest. Patient was found deceased in home, no hospitalization, no autopsy

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1371720&WAYBACKHISTORY=ON

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