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This is VAERS ID 959167

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 959167
VAERS Form:2
Age:84.0
Sex:Male
Location:Alabama
Vaccinated:2021-01-14
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: unknown
Current Illness:
Preexisting Conditions: Seizures were reported on vaccine form
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021.


Changed on 5/7/2021

VAERS ID: 959167 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Alabama
Vaccinated:2021-01-14
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: unknown
Current Illness:
Preexisting Conditions: Seizures were reported on vaccine form
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021.


Changed on 5/14/2021

VAERS ID: 959167 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Alabama
Vaccinated:2021-01-14
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: unknown
Current Illness:
Preexisting Conditions: Seizures were reported on vaccine form
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021.

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