National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 917117

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 917117
VAERS Form:2
Age:82.0
Sex:Male
Location:Arkansas
Vaccinated:2020-12-22
Onset:2020-12-28
Submitted:0000-00-00
Entered:2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-01
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: Quietapine, Mertazipine, Hydrocodone, Fentanyl
Current Illness: Yes
Preexisting Conditions: Yes
Allergies: None
Diagnostic Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.
CDC 'Split Type':

Write-up: After vaccination, patient tested positive for COVID-19. Patient was very ill and had numerous chronic health issues prior to vaccination. Facility had a number of patients who had already tested positive for COVID-19. Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk. This was unsuccessful and patient died.


Changed on 5/7/2021

VAERS ID: 917117 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Arkansas
Vaccinated:2020-12-22
Onset:2020-12-28
Submitted:0000-00-00
Entered:2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-01
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: Quietapine, Mertazipine, Hydrocodone, Fentanyl
Current Illness: Yes
Preexisting Conditions: Yes
Allergies: None None
Diagnostic Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.
CDC 'Split Type':

Write-up: After vaccination, patient tested positive for COVID-19. Patient was very ill and had numerous chronic health issues prior to vaccination. Facility had a number of patients who had already tested positive for COVID-19. Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk. This was unsuccessful and patient died.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=917117&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166