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This is VAERS ID 937434

History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 937434
VAERS Form:2
Age:70.0
Sex:Male
Location:Montana
Vaccinated:2021-01-07
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20 / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
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:
Current Illness: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.


Changed on 5/7/2021

VAERS ID: 937434 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Montana
Vaccinated:2021-01-07
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20 / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
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:
Current Illness: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.


Changed on 5/14/2021

VAERS ID: 937434 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Montana
Vaccinated:2021-01-07
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20 / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
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:
Current Illness: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=937434&WAYBACKHISTORY=ON

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