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This is VAERS ID 961776

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 961776
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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: Acetaminophen 325mg, Aspirin 81mg, Celecoxib 200mg, Docusate Sodium 100mg, Furosemide 40mg, Glimepiride 2mg, Lantus SoloStar 100unit/ml Pen-Injector, NovoLog FlexPen 100 Unit/ml Injection Pen, Senokot 8.6mg, Nu-Iron 150mg, Lisinopril, 20mg,
Current Illness: None
Preexisting Conditions: Hypertension, Type 2 Diabetes
Allergies: None Known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 1/13/2021 12:00 PM: Patient received COVID-19 Vaccine. 1/14/2021 21:00: Nurse performed routine rounds and the patient appeared okay. 1/14/2021 22:00: CNA discovered patient unresponsive in bed, began CPR, and called 911. 1/14/2021 23:08: Pronounced deceased.


Changed on 5/7/2021

VAERS ID: 961776 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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: Acetaminophen 325mg, Aspirin 81mg, Celecoxib 200mg, Docusate Sodium 100mg, Furosemide 40mg, Glimepiride 2mg, Lantus SoloStar 100unit/ml Pen-Injector, NovoLog FlexPen 100 Unit/ml Injection Pen, Senokot 8.6mg, Nu-Iron 150mg, Lisinopril, 20mg,
Current Illness: None
Preexisting Conditions: Hypertension, Type 2 Diabetes
Allergies: None Known Known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 1/13/2021 12:00 PM: Patient received COVID-19 Vaccine. 1/14/2021 21:00: Nurse performed routine rounds and the patient appeared okay. 1/14/2021 22:00: CNA discovered patient unresponsive in bed, began CPR, and called 911. 1/14/2021 23:08: Pronounced deceased.


Changed on 5/14/2021

VAERS ID: 961776 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-14
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: Acetaminophen 325mg, Aspirin 81mg, Celecoxib 200mg, Docusate Sodium 100mg, Furosemide 40mg, Glimepiride 2mg, Lantus SoloStar 100unit/ml Pen-Injector, NovoLog FlexPen 100 Unit/ml Injection Pen, Senokot 8.6mg, Nu-Iron 150mg, Lisinopril, 20mg,
Current Illness: None
Preexisting Conditions: Hypertension, Type 2 Diabetes
Allergies: None Known Known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 1/13/2021 12:00 PM: Patient received COVID-19 Vaccine. 1/14/2021 21:00: Nurse performed routine rounds and the patient appeared okay. 1/14/2021 22:00: CNA discovered patient unresponsive in bed, began CPR, and called 911. 1/14/2021 23:08: Pronounced deceased.

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