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This is VAERS ID 914805

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

VAERS ID: 914805
VAERS Form:2
Age:63.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon-
Current Illness: none
Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: RESIDENT CODED AND EXPIRED


Changed on 5/7/2021

VAERS ID: 914805 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon-
Current Illness: none
Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: RESIDENT CODED AND EXPIRED


Changed on 5/14/2021

VAERS ID: 914805 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Illinois
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-29
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: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon-
Current Illness: none
Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: RESIDENT CODED AND EXPIRED

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=914805&WAYBACKHISTORY=ON


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