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This is VAERS ID 963167

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 963167
VAERS Form:1
Age:88.0
Sex:Male
Location:Delaware
Vaccinated:2021-01-02
Onset:2021-01-04
Submitted:2021-01-08
Entered:2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE


Changed on 5/7/2021

VAERS ID: 963167 Before After
VAERS Form:1
Age:88.0
Sex:Male
Location:Delaware
Vaccinated:2021-01-02
Onset:2021-01-04
Submitted:2021-01-08
Entered:2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE


Changed on 5/14/2021

VAERS ID: 963167 Before After
VAERS Form:1
Age:88.0
Sex:Male
Location:Delaware
Vaccinated:2021-01-02
Onset:2021-01-04
Submitted:2021-01-08
Entered:2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=963167&WAYBACKHISTORY=ON

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