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This is VAERS ID 908105

History of Changes from the VAERS Wayback Machine

First Appeared on 12/24/2020

VAERS ID: 908105
VAERS Form:2
Age:54.0
Sex:Female
Location:California
Vaccinated:2020-12-09
Onset:2020-12-09
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS HG9N2 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Fatigue, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-18
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: hypertension, depression
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt experienced chill, fever and tiredness. on 12/22, pt''s family reported pt passed away. not certain about the relationship between her death and the flu shot but just reporting it


Changed on 12/30/2020

VAERS ID: 908105 Before After
VAERS Form:2
Age:54.0
Sex:Female
Location:California
Vaccinated:2020-12-09
Onset:2020-12-09
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS HG9N2 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Fatigue, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-18
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: hypertension, depression
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt experienced chill, fever and tiredness. on 12/22, pt''s family reported pt passed away. not certain about the relationship between her death and the flu shot but just reporting it


Changed on 5/7/2021

VAERS ID: 908105 Before After
VAERS Form:2
Age:54.0
Sex:Female
Location:California
Vaccinated:2020-12-09
Onset:2020-12-09
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS HG9N2 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Fatigue, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-18
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: hypertension, depression
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt experienced chill, fever and tiredness. on 12/22, pt''s family reported pt passed away. not certain about the relationship between her death and the flu shot but just reporting it


Changed on 5/14/2021

VAERS ID: 908105 Before After
VAERS Form:2
Age:54.0
Sex:Female
Location:California
Vaccinated:2020-12-09
Onset:2020-12-09
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS HG9N2 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Chills, Death, Fatigue, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-18
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: hypertension, depression
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt experienced chill, fever and tiredness. on 12/22, pt''s family reported pt passed away. not certain about the relationship between her death and the flu shot but just reporting it

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=908105&WAYBACKHISTORY=ON

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