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This is VAERS ID 933578

History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 933578
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2021-01-08
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021


Changed on 5/7/2021

VAERS ID: 933578 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2021-01-08
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021


Changed on 5/14/2021

VAERS ID: 933578 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2021-01-08
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=933578&WAYBACKHISTORY=ON


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