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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1754283

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Case Details

VAERS ID: 1754283 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-09-24
Onset:2021-09-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939901 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   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: Acetaminophen Tablet 650 MG Give 1 tablet by mouth every 6 hours as needed for General Discomfort Pharmacy Active 8/19/2021 17:38 8/19/2021 Furosemide Tablet 40 MG Give 1 tablet by mouth one time a day for Edema Pharmacy Active 8/20/2021
Current Illness: None
Preexisting Conditions: CKD, COPD, Diabetes, dementia
Allergies: Sulfa
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


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