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This is VAERS ID 959568

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 959568
VAERS Form:2
Age:70.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-16
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cerebral haemorrhage, Death, Intensive care, Loss of consciousness, Unresponsive to stimuli, Aneurysm ruptured

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None disclosed
Current Illness: None disclosed
Preexisting Conditions: None disclosed
Allergies: None disclosed
Diagnostic Lab Data: ROI not signed and we do not have access to these records as Clinic is not patient''s PCP
CDC 'Split Type':

Write-up: Patient received her first dose of the Moderna COVID-19 Vaccination on Saturday January 16th 2021 at approximately 12pm. She completed all necessary screening forms and was deemed to be at low risk for serious allergic reactions. She tolerated the vaccination well, and no complications or immediate adverse events occurred. She was observed for a full 15 mins per CDPHE/CDC guidelines and left the Clinic in stable condition after her observation period was complete. On the morning of Tuesday, January 19th, 2021, the patient was found unconscious and unresponsive by her husband. She was transferred by Ambulance to Hospital shortly thereafter. She was diagnosed with a brain bleed that was determined to be inoperable. She was transferred to other Hospital for higher level care. She was seen by neurosurgery and diagnosed with a ruptured aneurysm. She was treated in the ICU for 24 hours, at which point her team determined that the severity of her brain bleed would not respond to treatment. Supportive cares were withdrawn on Wednesday Jan 20th, and she passed away shortly thereafter.


Changed on 5/7/2021

VAERS ID: 959568 Before After
VAERS Form:2
Age:70.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-16
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cerebral haemorrhage, Death, Intensive care, Loss of consciousness, Unresponsive to stimuli, Aneurysm ruptured

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None disclosed
Current Illness: None disclosed
Preexisting Conditions: None disclosed
Allergies: None disclosed disclosed
Diagnostic Lab Data: ROI not signed and we do not have access to these records as Clinic is not patient''s PCP
CDC 'Split Type':

Write-up: Patient received her first dose of the Moderna COVID-19 Vaccination on Saturday January 16th 2021 at approximately 12pm. She completed all necessary screening forms and was deemed to be at low risk for serious allergic reactions. She tolerated the vaccination well, and no complications or immediate adverse events occurred. She was observed for a full 15 mins per CDPHE/CDC guidelines and left the Clinic in stable condition after her observation period was complete. On the morning of Tuesday, January 19th, 2021, the patient was found unconscious and unresponsive by her husband. She was transferred by Ambulance to Hospital shortly thereafter. She was diagnosed with a brain bleed that was determined to be inoperable. She was transferred to other Hospital for higher level care. She was seen by neurosurgery and diagnosed with a ruptured aneurysm. She was treated in the ICU for 24 hours, at which point her team determined that the severity of her brain bleed would not respond to treatment. Supportive cares were withdrawn on Wednesday Jan 20th, and she passed away shortly thereafter.


Changed on 5/14/2021

VAERS ID: 959568 Before After
VAERS Form:2
Age:70.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-16
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cerebral haemorrhage, Death, Intensive care, Loss of consciousness, Unresponsive to stimuli, Aneurysm ruptured

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None disclosed
Current Illness: None disclosed
Preexisting Conditions: None disclosed
Allergies: None disclosed disclosed
Diagnostic Lab Data: ROI not signed and we do not have access to these records as Clinic is not patient''s PCP
CDC 'Split Type':

Write-up: Patient received her first dose of the Moderna COVID-19 Vaccination on Saturday January 16th 2021 at approximately 12pm. She completed all necessary screening forms and was deemed to be at low risk for serious allergic reactions. She tolerated the vaccination well, and no complications or immediate adverse events occurred. She was observed for a full 15 mins per CDPHE/CDC guidelines and left the Clinic in stable condition after her observation period was complete. On the morning of Tuesday, January 19th, 2021, the patient was found unconscious and unresponsive by her husband. She was transferred by Ambulance to Hospital shortly thereafter. She was diagnosed with a brain bleed that was determined to be inoperable. She was transferred to other Hospital for higher level care. She was seen by neurosurgery and diagnosed with a ruptured aneurysm. She was treated in the ICU for 24 hours, at which point her team determined that the severity of her brain bleed would not respond to treatment. Supportive cares were withdrawn on Wednesday Jan 20th, and she passed away shortly thereafter.

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