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From the 5/7/2021 release of VAERS data:

This is VAERS ID 890067



Case Details

VAERS ID: 890067 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Nevada  
Vaccinated:2020-09-08
Onset:2020-09-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-10-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ460AB / 1 LA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 4F99G / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Mechanical ventilation
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-10-12
   Days after onset: 34
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Diabetes, CVD, and hyperlipidemia
Allergies: NOne
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Wife called us on 10/15 to inform that patient did not do well after the vaccines. He was on ventilator for 5 days, then passed away.


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