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This is VAERS ID 947662

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 947662
VAERS Form:2
Age:84.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Somnolence, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC 'Split Type':

Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death


Changed on 5/7/2021

VAERS ID: 947662 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Somnolence, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC 'Split Type':

Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death


Changed on 5/14/2021

VAERS ID: 947662 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Minnesota
Vaccinated:2020-12-30
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Somnolence, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC 'Split Type':

Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=947662&WAYBACKHISTORY=ON

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