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This is VAERS ID 1764856

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1764856
VAERS Form:2
Age:70.0
Sex:Male
Location:Kentucky
Vaccinated:2021-01-14
Onset:2021-09-22
Submitted:0000-00-00
Entered:2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-09-22
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: Unknown
Current Illness:
Preexisting Conditions: Metastatic Lung Cancer
Allergies: Unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt died after contracting COVID-19 in early August 2021.

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