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This is VAERS ID 1754275

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1754275
VAERS Form:2
Age:48.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-06-04
Onset:2021-09-30
Submitted:0000-00-00
Entered:2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017C21A / 2 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-09-30
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.

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