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This is VAERS ID 962714

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 962714
VAERS Form:2
Age:80.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-19
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac failure congestive, Chronic respiratory failure, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-10
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 suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.
Current Illness: Aspiration pneumonia (dx on 12/16/2020)
Preexisting Conditions: Congestive heart failure, chronic respiratory failure, dementia, chronic mylomonocytic leukemia, chronic COPD, coronary artery disease, dysphagia.
Allergies: lisinopril, shellfish
Diagnostic Lab Data: None, no adverse events were observed relating to the COVID vaccine.
CDC 'Split Type':

Write-up: We do not believe that the patient''s death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.


Changed on 5/7/2021

VAERS ID: 962714 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-19
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac failure congestive, Chronic respiratory failure, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-10
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 suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.
Current Illness: Aspiration pneumonia (dx on 12/16/2020)
Preexisting Conditions: Congestive heart failure, chronic respiratory failure, dementia, chronic mylomonocytic leukemia, chronic COPD, coronary artery disease, dysphagia.
Allergies: lisinopril, shellfish shellfish
Diagnostic Lab Data: None, no adverse events were observed relating to the COVID vaccine.
CDC 'Split Type':

Write-up: We do not believe that the patient''s death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.


Changed on 5/14/2021

VAERS ID: 962714 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-19
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac failure congestive, Chronic respiratory failure, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-10
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 suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.
Current Illness: Aspiration pneumonia (dx on 12/16/2020)
Preexisting Conditions: Congestive heart failure, chronic respiratory failure, dementia, chronic mylomonocytic leukemia, chronic COPD, coronary artery disease, dysphagia.
Allergies: lisinopril, shellfish shellfish
Diagnostic Lab Data: None, no adverse events were observed relating to the COVID vaccine.
CDC 'Split Type':

Write-up: We do not believe that the patient''s death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.

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