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This is VAERS ID 924186

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 924186
VAERS Form:2
Age:91.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-03
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:2021-01-03
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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired 1/3/21


Changed on 5/7/2021

VAERS ID: 924186 Before After
VAERS Form:2
Age:91.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-03
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:2021-01-03
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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa Sulfa
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired 1/3/21


Changed on 5/14/2021

VAERS ID: 924186 Before After
VAERS Form:2
Age:91.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-30
Onset:2021-01-03
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:2021-01-03
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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa Sulfa
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired 1/3/21

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