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This is VAERS ID 1737167

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/1/2021

VAERS ID: 1737167
VAERS Form:2
Age:93.0
Sex:Female
Location:Georgia
Vaccinated:2021-02-11
Onset:2021-08-19
Submitted:0000-00-00
Entered:2021-09-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EM9810 / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute respiratory failure, Bronchiectasis, Cough, Death, Pulmonary embolism, Vaccine breakthrough infection, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-08-26
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cardiovascular disease
Allergies:
Diagnostic Lab Data: 08/19/2021 PCR+ COVID-19 test
CDC 'Split Type':

Write-up: Breakthrough COVID-19 case with symptom onset 8/19/2021: Cough. Hospitalized 8/19/2021 for unknown duration. Death 8/26/2021. Vital records COD = ACUTE HYPOXIC RESPIRATORY FAILURE, COVID-19. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: BRONCHIECHIECTASIS PULMONARY EMBOLUS; Place of death: HOSPITAL;

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