National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 961434

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 961434
VAERS Form:2
Age:94.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Pupil fixed, Resuscitation, Musculoskeletal stiffness, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC) ? Nephrology Stage 3 chronic kidney disease ? Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis ? Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.


Changed on 5/7/2021

VAERS ID: 961434 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Pupil fixed, Resuscitation, Musculoskeletal stiffness, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC) ?   Nephrology Stage 3 chronic kidney disease ?   Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis ?   Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.


Changed on 5/14/2021

VAERS ID: 961434 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Pupil fixed, Resuscitation, Musculoskeletal stiffness, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC)   ? Nephrology Stage 3 chronic kidney disease   ? Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis   ? Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.


Changed on 10/1/2021

VAERS ID: 961434 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Death, Pupil fixed, Resuscitation, Musculoskeletal stiffness, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC) ? Nephrology Stage 3 chronic kidney disease ? Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis ? Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=961434&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166