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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 90265 |
VAERS Form: | |
Age: | 52.3 |
Sex: | Male |
Location: | California |
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-10-02 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLU: UNK. INFLUENZA VACCINE / UNCLASSIFIED | 6F71223 / - | - / - |
Administered by: Private Purchased by: Unknown
Symptoms: ALLERG REACT, FLU SYND, ANAPHYL, EDEMA LARYNX, ASPHYXIA
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-10-02 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLU: UNK. INFLUENZA VACCINE INFLUENZA (SEASONAL) (NO BRAND NAME) / UNCLASSIFIED UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
Administered by: Private Unknown Purchased by: Unknown
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema, ALLERG REACT, FLU SYND, ANAPHYL, EDEMA LARYNX, ASPHYXIA
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
Administered by: Unknown Purchased by: Unknown
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
Administered by: Unknown Purchased by: Unknown
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - | - / - |
Administered by: Unknown Private Purchased by: Unknown Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / - UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Vaccinated: | 1996-09-18 |
Onset: | 1996-09-22 |
Submitted: | 1996-09-27 |
Entered: | 1996-09-30 |
Vaccination / Manufacturer | Lot / Dose | Site / Route |
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER | 6F71223 / UNK | - / - |
Administered by: Private Purchased by: Private
Symptoms: Anaphylactoid reaction, Asphyxia, Hypersensitivity, Influenza, Laryngeal oedema
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:1996-09-22
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CO6786
Write-up: death, flu-like sx 3 days p/shot;
Link To This Search Result:
https://medalerts.org/vaersdb/findfield.php?IDNUMBER=90265&WAYBACKHISTORY=ON
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