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This is VAERS ID 924126

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 924126
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: resident expired 1/1/2021


Changed on 5/7/2021

VAERS ID: 924126 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin vicodin
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: resident expired 1/1/2021


Changed on 5/14/2021

VAERS ID: 924126 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin vicodin
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: resident expired 1/1/2021

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