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This is VAERS ID 1761641

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1761641
VAERS Form:2
Age:87.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-12
Onset:2021-09-17
Submitted:0000-00-00
Entered:2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Dyspnoea, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-09-29
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: Covid antigen test on 9/17/21 for admission and sx
CDC 'Split Type':

Write-up: pt was admitted on 9/17/21 with increased shortness of breath, pt was a DNR/DNI at time of hospitaliztion, pt was made hospice on 9/29/21 pt expired 9/29/21

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