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This is VAERS ID 1424120

History of Changes from the VAERS Wayback Machine

First Appeared on 6/25/2021

VAERS ID: 1424120
VAERS Form:2
Age:83.0
Sex:Female
Location:Indiana
Vaccinated:2021-04-11
Onset:2021-04-23
Submitted:0000-00-00
Entered:2021-06-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Condition aggravated, Death, Diabetes mellitus, Hypertension, Respiratory failure, Polymerase chain reaction, Nucleic acid test, COVID-19

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-23
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: COVID-19
Preexisting Conditions: Diabetes Mellitus Hypertension
Allergies:
Diagnostic Lab Data: RT-PCR or other NAAT test
CDC 'Split Type':

Write-up: Death 04/23/2021 Causes of death listed on death certificate: 1. hypoxic respiratory failure 2. covid 19 3. diabetes mellitus 4. hypertension

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1424120&WAYBACKHISTORY=ON

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