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This is VAERS ID 962995

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 962995
VAERS Form:2
Age:61.0
Sex:Male
Location:California
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unknown
Preexisting Conditions: Unknown
Allergies: No known allergies.
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic.


Changed on 5/7/2021

VAERS ID: 962995 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:California
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unknown
Preexisting Conditions: Unknown
Allergies: No known allergies. allergies.
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic.


Changed on 5/21/2021

VAERS ID: 962995 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:California
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unknown
Preexisting Conditions: Unknown
Allergies: No known allergies. allergies.
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=962995&WAYBACKHISTORY=ON


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