National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts.org
Search Results

This is VAERS ID 963388

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 963388
VAERS Form:2
Age:88.0
Sex:Female
Location:North Dakota
Vaccinated:2021-01-05
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: 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: Albuterol, Aspirin, Ativan, Ayr Saline Nasal, Biotene Dry mouth moisturizing spray, docusate sodium, Florajen 3, gabapentin, hydralazine HCL, Hydrocortisone acetate/LI, Isosource VHN 1.5 cal, ketoconazole, Lasix, lopressor, multivitamin, pl
Current Illness: No known illnesses at time of vaccination.
Preexisting Conditions: COPD, Aptyalism, upper respiratory tract infection due to Influenza, acute bronchitis, Pnuemonia, generalized anxiety disorder, impaired intestinal carbohydrate absorption, heart failure, GERD without esophagitis, long term current use of anticoagulant, transplanted skin present, history of UTISs, constipation, Periipheral vascular disease, chronic pain, history of amputation of lower limb above knee, sick sinus syndrome, candidiasis of skin, dysuria, Cerebrovasxular disease, cellulitis of toe of right foot, actinic keratosis, psoriasis, hyperlipidemia, intertrigo, dyspnea, dysphagia, and attention to gastrostomy, history of impacted cerumen in ears.
Allergies: Ceftriaxone sodium, Augmentin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died unexpectedly 5 days after receiving vaccine (1/10/2021).


Changed on 5/7/2021

VAERS ID: 963388 Before After
VAERS Form:2
Age:88.0
Sex:Female
Location:North Dakota
Vaccinated:2021-01-05
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: 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: Albuterol, Aspirin, Ativan, Ayr Saline Nasal, Biotene Dry mouth moisturizing spray, docusate sodium, Florajen 3, gabapentin, hydralazine HCL, Hydrocortisone acetate/LI, Isosource VHN 1.5 cal, ketoconazole, Lasix, lopressor, multivitamin, pl
Current Illness: No known illnesses at time of vaccination.
Preexisting Conditions: COPD, Aptyalism, upper respiratory tract infection due to Influenza, acute bronchitis, Pnuemonia, generalized anxiety disorder, impaired intestinal carbohydrate absorption, heart failure, GERD without esophagitis, long term current use of anticoagulant, transplanted skin present, history of UTISs, constipation, Periipheral vascular disease, chronic pain, history of amputation of lower limb above knee, sick sinus syndrome, candidiasis of skin, dysuria, Cerebrovasxular disease, cellulitis of toe of right foot, actinic keratosis, psoriasis, hyperlipidemia, intertrigo, dyspnea, dysphagia, and attention to gastrostomy, history of impacted cerumen in ears.
Allergies: Ceftriaxone sodium, Augmentin Augmentin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died unexpectedly 5 days after receiving vaccine (1/10/2021).


Changed on 5/21/2021

VAERS ID: 963388 Before After
VAERS Form:2
Age:88.0
Sex:Female
Location:North Dakota
Vaccinated:2021-01-05
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: 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: Albuterol, Aspirin, Ativan, Ayr Saline Nasal, Biotene Dry mouth moisturizing spray, docusate sodium, Florajen 3, gabapentin, hydralazine HCL, Hydrocortisone acetate/LI, Isosource VHN 1.5 cal, ketoconazole, Lasix, lopressor, multivitamin, pl
Current Illness: No known illnesses at time of vaccination.
Preexisting Conditions: COPD, Aptyalism, upper respiratory tract infection due to Influenza, acute bronchitis, Pnuemonia, generalized anxiety disorder, impaired intestinal carbohydrate absorption, heart failure, GERD without esophagitis, long term current use of anticoagulant, transplanted skin present, history of UTISs, constipation, Periipheral vascular disease, chronic pain, history of amputation of lower limb above knee, sick sinus syndrome, candidiasis of skin, dysuria, Cerebrovasxular disease, cellulitis of toe of right foot, actinic keratosis, psoriasis, hyperlipidemia, intertrigo, dyspnea, dysphagia, and attention to gastrostomy, history of impacted cerumen in ears.
Allergies: Ceftriaxone sodium, Augmentin Augmentin
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died unexpectedly 5 days after receiving vaccine (1/10/2021).

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=963388&WAYBACKHISTORY=ON


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