National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 418006

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 418006
VAERS Form:
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3773BA / 3 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 7/12/2011

VAERS ID: 418006 Before After
VAERS Form:
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 3 RA / IM
FLU(10-11): INFLUENZA (SEASONAL) (FLUZONE 10-11) / SANOFI PASTEUR UT3773BA / 3 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 7/7/2013

VAERS ID: 418006 Before After
VAERS Form:
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 3 RA / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 3 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 9/14/2017

VAERS ID: 418006 Before After
VAERS Form:(blank) 1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 3 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 2/14/2018

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 6/14/2018

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 8/14/2018

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 9/14/2018

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 10/14/2018

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 12/24/2020

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 12/30/2020

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 5/7/2021

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).


Changed on 5/14/2021

VAERS ID: 418006 Before After
VAERS Form:1
Age:68.0
Sex:Male
Location:Idaho
Vaccinated:2010-11-30
Onset:2010-11-30
Submitted:2011-03-01
Entered:2011-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT3773BA / 4 RA / IM

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-11-30
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 at present time
Preexisting Conditions: COPD; Reflux; HTN; Gout; Allergy to salmon
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': ID11003

Write-up: Pt. came into clinic for annual flu shot. Was non-ill appearing. Wife received same flu shot at the same time with no adverse rxn. Pt. then went home and later passed away in house (residence).

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=418006&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166