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This is VAERS ID 92136

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 92136
VAERS Form:
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1996-1997 / PARKE-DAVIS 00276P / 0 A / IM

Administered by: Private      Purchased by: Unknown
Symptoms: REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 12/8/2009

VAERS ID: 92136 Before After
VAERS Form:
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-21 1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUOGEN 1996-1997 INFLUENZA (SEASONAL) (FLUOGEN 96-97) / PARKE-DAVIS 00276P / 0 A / IM

Administered by: Private      Purchased by: Unknown Other
Symptoms: Unevaluable event, REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': (blank) 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 8/31/2010

VAERS ID: 92136 Before After
VAERS Form:
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN 96-97) INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 0 A / IM

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 7/7/2013

VAERS ID: 92136 Before After
VAERS Form:
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 0 A / IM
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 0 A / IM

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 5/14/2017

VAERS ID: 92136 Before After
VAERS Form:
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 0 A - / IM IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 9/14/2017

VAERS ID: 92136 Before After
VAERS Form:(blank) 1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 0 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 2/14/2018

VAERS ID: 92136 Before After
VAERS Form:1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 6/14/2018

VAERS ID: 92136 Before After
VAERS Form:1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 8/14/2018

VAERS ID: 92136 Before After
VAERS Form:1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 9/14/2018

VAERS ID: 92136 Before After
VAERS Form:1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;


Changed on 10/14/2018

VAERS ID: 92136 Before After
VAERS Form:1
Age:63.0
Sex:Female
Location:Kansas
Vaccinated:1996-11-05
Onset:1996-11-05
Submitted:1996-11-11
Entered:1996-11-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUOGEN) / PARKE-DAVIS 00276P / 1 - / IM A

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1996-11-05
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: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: hx of heart disease?NKDA/no allergy to eggs;not taking coumadin/prev recv flu vax w/o rxn;
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': 0010150960083

Write-up: pt recv vax 5NOV96 & that evening pt died;pt had a hx of heart disease;pt was not allergic to eggs & had prev recv the flu vax w/o rxn;pt was not taking Coumadin;responsible MD does not think the death was r/t vax;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=92136&WAYBACKHISTORY=ON


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