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

This is VAERS ID 1759157

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Case Details

VAERS ID: 1759157 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2020-12-22
Onset:2020-12-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Communication disorder, Death, Decreased appetite
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650mg @ 9 AM/1 PM/5 PM
Current Illness: None
Preexisting Conditions: Dementia
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cessation of talking and eating followed by death.


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