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This is VAERS ID 940855

History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 940855
VAERS Form:2
Age:79.0
Sex:Female
Location:Arkansas
Vaccinated:2021-01-12
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

Administered by: Senior Living      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)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.


Changed on 5/7/2021

VAERS ID: 940855 Before After
VAERS Form:2
Age:79.0
Sex:Female
Location:Arkansas
Vaccinated:2021-01-12
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

Administered by: Senior Living      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)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None None
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.


Changed on 5/14/2021

VAERS ID: 940855 Before After
VAERS Form:2
Age:79.0
Sex:Female
Location:Arkansas
Vaccinated:2021-01-12
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

Administered by: Senior Living      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)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None None
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=940855&WAYBACKHISTORY=ON

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