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This is VAERS ID 1759593

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1759593
VAERS Form:2
Age:76.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-04-13
Onset:2021-09-06
Submitted:0000-00-00
Entered:2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044B21A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, COVID-19

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-09-18
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: 12     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Hospitalized for COVID-19 on 9/6/21. Passed away on 9/18/21.

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