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This is VAERS ID 930154

History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 930154
VAERS Form:2
Age:60.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-05
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa
Diagnostic Lab Data:
CDC 'Split Type': VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.


Changed on 5/7/2021

VAERS ID: 930154 Before After
VAERS Form:2
Age:60.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-05
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa Sulfa
Diagnostic Lab Data:
CDC 'Split Type': VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.


Changed on 5/14/2021

VAERS ID: 930154 Before After
VAERS Form:2
Age:60.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-05
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa Sulfa
Diagnostic Lab Data:
CDC 'Split Type': VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.

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