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This is VAERS ID 36644

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 36644
VAERS Form:
Age:72.5
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1991-1992 / PARKE-DAVIS 0127P / 2 LA / -

Administered by: Public      Purchased by: Unknown
Symptoms: MALAISE, DEHYDRAT, RESPIRAT DIS, FIBRILLAT VENT, HYPOXIA

Life Threatening? No
Birth Defect? No
Died? No
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 12/8/2009

VAERS ID: 36644 Before After
VAERS Form:
Age:72.5 72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-12-03 1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1991-1992 INFLUENZA (SEASONAL) (FLUOGEN 91-92) / PARKE-DAVIS 0127P / 2 LA / -

Administered by: Public Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation, MALAISE, DEHYDRAT, RESPIRAT DIS, FIBRILLAT VENT, HYPOXIA

Life Threatening? No
Birth Defect? No
Died? No Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 8/31/2010

VAERS ID: 36644 Before After
VAERS Form:
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN 91-92) INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 7/7/2013

VAERS ID: 36644 Before After
VAERS Form:
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / -
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 10/13/2013

VAERS ID: 36644 Before After
VAERS Form:
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / - UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 3/14/2015

VAERS ID: 36644 Before After
VAERS Form:
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Aspiration, Death, Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 5/14/2017

VAERS ID: 36644 Before After
VAERS Form:
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Aspiration, Death, Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 9/14/2017

VAERS ID: 36644 Before After
VAERS Form:(blank) 1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 2 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 2/14/2018

VAERS ID: 36644 Before After
VAERS Form:1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 6/14/2018

VAERS ID: 36644 Before After
VAERS Form:1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 8/14/2018

VAERS ID: 36644 Before After
VAERS Form:1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 9/14/2018

VAERS ID: 36644 Before After
VAERS Form:1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;


Changed on 10/14/2018

VAERS ID: 36644 Before After
VAERS Form:1
Age:72.0
Sex:Male
Location:Georgia
Vaccinated:1991-09-23
Onset:1991-09-25
Submitted:1991-10-01
Entered:1991-11-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 0127P / 3 LA / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Dehydration, Hypoxia, Malaise, Respiratory disorder, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-09-28
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: Gastroenteritis
Preexisting Conditions: moderate to marked atherosclerosis, coronary artery
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': GA91311

Write-up: Pt became ill 2 days following inject; admitted to hosp because of dehydration; died 28SEP91; death certificate-ventricular fibrillation, hypoxia, aspiration, gastric contents;

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