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This is VAERS ID 964671

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 964671
VAERS Form:2
Age:100.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-18
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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: Omeprazole, metoprolol, prilosec,, isorbide, senna, nitro, lasix, fluticasone
Current Illness: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Preexisting Conditions: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Allergies: NKDA, NKFA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Death on 1-5-21


Changed on 5/7/2021

VAERS ID: 964671 Before After
VAERS Form:2
Age:100.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-18
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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: Omeprazole, metoprolol, prilosec,, isorbide, senna, nitro, lasix, fluticasone
Current Illness: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Preexisting Conditions: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Allergies: NKDA, NKFA NKFA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Death on 1-5-21


Changed on 5/14/2021

VAERS ID: 964671 Before After
VAERS Form:2
Age:100.0
Sex:Male
Location:Alaska
Vaccinated:2020-12-18
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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: Omeprazole, metoprolol, prilosec,, isorbide, senna, nitro, lasix, fluticasone
Current Illness: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Preexisting Conditions: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Allergies: NKDA, NKFA NKFA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Death on 1-5-21

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