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This is VAERS ID 1737079

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/1/2021

VAERS ID: 1737079
VAERS Form:2
Age:55.0
Sex:Male
Location:Minnesota
Vaccinated:2021-07-19
Onset:2021-08-19
Submitted:0000-00-00
Entered:2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939902 / 1 LA / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Aneurysm, Death, Fall, Headache, Malaise

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-09-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin
Diagnostic Lab Data: Rushed to emergency hospital 9/25/2021 then air lifted to another HCF
CDC 'Split Type':

Write-up: Severe headache within 4 hours of shot and after 4 days of feeling very unwell Pt stood up and fell over instantly of and aneurysm and died .I lost my partner of 23 years due to vaccination

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