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This is VAERS ID 969699

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 969699
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-19
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #027L20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide
Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker
Preexisting Conditions: Coronary heart disease
Allergies: None
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: Patient died.


Changed on 5/7/2021

VAERS ID: 969699 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-19
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #027L20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide
Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker
Preexisting Conditions: Coronary heart disease
Allergies: None None
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: Patient died.


Changed on 5/14/2021

VAERS ID: 969699 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:California
Vaccinated:2021-01-19
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #027L20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide
Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker
Preexisting Conditions: Coronary heart disease
Allergies: None None
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: Patient died.

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