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This is VAERS ID 789121

History of Changes from the VAERS Wayback Machine

First Appeared on 12/14/2018

VAERS ID: 789121
VAERS Form:2
Age:58.0
Sex:Male
Location:Oregon
Vaccinated:2018-10-22
Onset:2018-11-27
Submitted:0000-00-00
Entered:2018-11-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UI986AB / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2018-11-27
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: Albuterol; alprazolam; aspirin; atenolol; atorvastatin; bisoprolol; cholecalciferol; ciclopirox; duloxetine; empagliflozin; fenofibrate micronized; fish oil; fluoxetine; glimepiride; HUMILIN R; hydrocodone-acetaminophen; lamotrigine; Lisino
Current Illness: no known acute illness
Preexisting Conditions: Hypertension; tobacco abuse; gouty nephropathy; chondromalacia patella; chronic pain (multiple sites); morbid obesity; hypercholesterolemia; chronic pancreatitis; alcohol dependence remission; insomnia; diabetic periopheral neuropathy; cardiomegaly 30% risk CAD; hypertriglyceridemia; anxiety disorder; coronary artery disease; dysphagia; sleep apnea; diabetes type 2 with complications
Allergies: Buproprion, escitalopram oxalate, mirtazapine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Patient deceased on 11/27/18. At time of this report, reason of death is unknown, per reporting guidelines from CDC this report is being submitted by administering facility as immunization was given approximately one month prior to death of patient. No known adverse event was reported by patient or other family member directly related to vaccine administration.


Changed on 12/24/2020

VAERS ID: 789121 Before After
VAERS Form:2
Age:58.0
Sex:Male
Location:Oregon
Vaccinated:2018-10-22
Onset:2018-11-27
Submitted:0000-00-00
Entered:2018-11-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UI986AB / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2018-11-27
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: Albuterol; alprazolam; aspirin; atenolol; atorvastatin; bisoprolol; cholecalciferol; ciclopirox; duloxetine; empagliflozin; fenofibrate micronized; fish oil; fluoxetine; glimepiride; HUMILIN R; hydrocodone-acetaminophen; lamotrigine; Lisino
Current Illness: no known acute illness
Preexisting Conditions: Hypertension; tobacco abuse; gouty nephropathy; chondromalacia patella; chronic pain (multiple sites); morbid obesity; hypercholesterolemia; chronic pancreatitis; alcohol dependence remission; insomnia; diabetic periopheral neuropathy; cardiomegaly 30% risk CAD; hypertriglyceridemia; anxiety disorder; coronary artery disease; dysphagia; sleep apnea; diabetes type 2 with complications
Allergies: Buproprion, escitalopram oxalate, mirtazapine mirtazapine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Patient deceased on 11/27/18. At time of this report, reason of death is unknown, per reporting guidelines from CDC this report is being submitted by administering facility as immunization was given approximately one month prior to death of patient. No known adverse event was reported by patient or other family member directly related to vaccine administration.


Changed on 12/30/2020

VAERS ID: 789121 Before After
VAERS Form:2
Age:58.0
Sex:Male
Location:Oregon
Vaccinated:2018-10-22
Onset:2018-11-27
Submitted:0000-00-00
Entered:2018-11-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UI986AB / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2018-11-27
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: Albuterol; alprazolam; aspirin; atenolol; atorvastatin; bisoprolol; cholecalciferol; ciclopirox; duloxetine; empagliflozin; fenofibrate micronized; fish oil; fluoxetine; glimepiride; HUMILIN R; hydrocodone-acetaminophen; lamotrigine; Lisino
Current Illness: no known acute illness
Preexisting Conditions: Hypertension; tobacco abuse; gouty nephropathy; chondromalacia patella; chronic pain (multiple sites); morbid obesity; hypercholesterolemia; chronic pancreatitis; alcohol dependence remission; insomnia; diabetic periopheral neuropathy; cardiomegaly 30% risk CAD; hypertriglyceridemia; anxiety disorder; coronary artery disease; dysphagia; sleep apnea; diabetes type 2 with complications
Allergies: Buproprion, escitalopram oxalate, mirtazapine mirtazapine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: Patient deceased on 11/27/18. At time of this report, reason of death is unknown, per reporting guidelines from CDC this report is being submitted by administering facility as immunization was given approximately one month prior to death of patient. No known adverse event was reported by patient or other family member directly related to vaccine administration.

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