National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

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

This is VAERS ID 1371740

Case Details

VAERS ID: 1371740 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Minnesota  
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0146214 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Remeron, Tylenol, Abilify, Senna, Polyethylene Glycol, Vitamin D3, Flomax, Mirabegron, Morphine Sulfate
Current Illness: HTN
Preexisting Conditions: Vascular Dementia, Depression, HTN, BPH, History of COVID-19
Allergies: Lisinopril, Hydrochlorothiazide
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident was found in his bed to be passed away. He had been on Hospice.

New Search

Link To This Search Result:

Government Disclaimer on use of this data

Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166