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This is VAERS ID 926269

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 926269
VAERS Form:2
Age:74.0
Sex:Male
Location:Maryland
Vaccinated:2021-01-04
Onset:2021-01-05
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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: Acetaminophen Tablet 325 MG, Enulose Solution 10 GM/15ML (Lactulose Encephalopathy), HYDROcodone-Acetaminophen Tablet 5-325 MG, Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide, Potassium Chloride ER Tablet Extended Release 20 ME
Current Illness: Fracture of right superior and inferior pubic rami, fracture of the right sacral alla, and fracture of the L3 vertebral body. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
Preexisting Conditions: Abdominal aortic aneurysm CHRONIC OBSTRUCTIVE PULMONARY DISEASE tobacco abuse, EtOH abuse Ambulatory dysfunction, debility, high risk for falls, deconditioning, ambulatory dysfunction/debility/deconditioning/high fall risk/generalized weakness MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED PERSONAL HISTORY OF MALARIA
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt last seen at 1200 by nurse for ID band check. No visible signs of distress noted. Pt states "I just want to be left alone". 1230 nurse was called to pt room. Pt was noted unresponsive, no pulse and respiration noted. CPR started immediately, at 1239 first shock given. 1245 EMT took over, at 1319 EMT called time of death

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