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This is VAERS ID 378027

History of Changes from the VAERS Wayback Machine

First Appeared on 2/5/2010

VAERS ID: 378027
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:0000-00-00
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 4/7/2010

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:0000-00-00 2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 6/2/2010

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (INFLUENZA A (H1N1) 2009 MONOVALENT) INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 8/31/2010

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 1/4/2011

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 4/13/2011

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 5/13/2011

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 6/11/2011

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 11/13/2012

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) SANOFI) INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 6/14/2014

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 3/14/2015

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms: Alanine aminotransferase increased, Arteriosclerosis, Aspartate aminotransferase increased, Blood bilirubin, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood potassium decreased, Blood sodium increased, Cardiac arrest, Coronary artery thrombosis, Death, Electrocardiogram abnormal, Mydriasis, Protein total decreased, Pupil fixed, Vomiting, Troponin increased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 2/14/2017

VAERS ID: 378027 Before After
VAERS Form:
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI) INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 0 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 9/14/2017

VAERS ID: 378027 Before After
VAERS Form:(blank) 1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 0 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 2/14/2018

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 6/14/2018

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 8/14/2018

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 9/14/2018

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 10/14/2018

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 12/24/2020

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 12/30/2020

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 5/7/2021

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.


Changed on 5/14/2021

VAERS ID: 378027 Before After
VAERS Form:1
Age:67.0
Sex:Female
Location:Virginia
Vaccinated:2010-01-12
Onset:2010-01-15
Submitted:2010-01-21
Entered:2010-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(H1N1): INFLUENZA (H1N1) (H1N1 (MONOVALENT) (SANOFI)) / SANOFI PASTEUR UP074AA / 1 LA / IM

Administered by: Other      Purchased by: Public
Symptoms:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-15
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: None reported
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: No adverse reactions within first hour after vaccination administered. Notified of client''s death on 01/15/2010.

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