National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts.org
Search Results

This is VAERS ID 963235

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 963235
VAERS Form:2
Age:94.0
Sex:Female
Location:Texas
Vaccinated:2021-01-04
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test, Exposure to SARS-CoV-2

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol
Current Illness:
Preexisting Conditions: HTN, Depression, Atherosclerotic heart disease, GERD, Hypothyroidism, Chronic renal failure stage 3, CHF
Allergies: Lisinopril
Diagnostic Lab Data: COVID test
CDC 'Split Type':

Write-up: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021


Changed on 5/7/2021

VAERS ID: 963235 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Texas
Vaccinated:2021-01-04
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test, Exposure to SARS-CoV-2

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol
Current Illness:
Preexisting Conditions: HTN, Depression, Atherosclerotic heart disease, GERD, Hypothyroidism, Chronic renal failure stage 3, CHF
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: COVID test
CDC 'Split Type':

Write-up: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021


Changed on 5/21/2021

VAERS ID: 963235 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Texas
Vaccinated:2021-01-04
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Work      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test, Exposure to SARS-CoV-2

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol
Current Illness:
Preexisting Conditions: HTN, Depression, Atherosclerotic heart disease, GERD, Hypothyroidism, Chronic renal failure stage 3, CHF
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: COVID test
CDC 'Split Type':

Write-up: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=963235&WAYBACKHISTORY=ON


Copyright © 2022 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166