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This is VAERS ID 954780

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 954780
VAERS Form:2
Age:82.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-05
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pulse absent, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
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: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood
Diagnostic Lab Data: None.
CDC 'Split Type':

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.


Changed on 5/7/2021

VAERS ID: 954780 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-05
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pulse absent, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
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: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood Shellfish/Seafood
Diagnostic Lab Data: None.
CDC 'Split Type':

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.


Changed on 5/14/2021

VAERS ID: 954780 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Michigan
Vaccinated:2021-01-05
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Pulse absent, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
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: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood Shellfish/Seafood
Diagnostic Lab Data: None.
CDC 'Split Type':

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=954780&WAYBACKHISTORY=ON


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