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This is VAERS ID 1758912

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1758912
VAERS Form:2
Age:79.0
Sex:Male
Location:Tennessee
Vaccinated:2021-02-26
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 RA / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Inappropriate schedule of product administration, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-10-02
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: Patient tested positive for COVID-19 9/23/2021. Hospitilized 9/23/2021. Patient was fully vaccinated 2/26/21 and 04/03/2021 with Moderna. Paitnet expired 10/02/2021

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