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This is VAERS ID 975421

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 975421
VAERS Form:2
Age:60.0
Sex:Male
Location:Missouri
Vaccinated:2021-01-07
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-01
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: unknown medications for COPD, nebulizers, inhalers
Current Illness: Patient had reported on 8/8/2019 having arthritis, leg wounds, COPD, asthma, incontinence of bladder. Resident may also have had blood clots in his legs, per his sister.
Preexisting Conditions: Same as in Item 11.
Allergies: none known
Diagnostic Lab Data: Unknown by this reporter
CDC 'Split Type':

Write-up: Resident was discovered deceased in his apartment on 1/23/2021. Family had


Changed on 5/7/2021

VAERS ID: 975421 Before After
VAERS Form:2
Age:60.0
Sex:Male
Location:Missouri
Vaccinated:2021-01-07
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-01
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: unknown medications for COPD, nebulizers, inhalers
Current Illness: Patient had reported on 8/8/2019 having arthritis, leg wounds, COPD, asthma, incontinence of bladder. Resident may also have had blood clots in his legs, per his sister.
Preexisting Conditions: Same as in Item 11.
Allergies: none known known
Diagnostic Lab Data: Unknown by this reporter
CDC 'Split Type':

Write-up: Resident was discovered deceased in his apartment on 1/23/2021. Family had


Changed on 5/14/2021

VAERS ID: 975421 Before After
VAERS Form:2
Age:60.0
Sex:Male
Location:Missouri
Vaccinated:2021-01-07
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-01
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: unknown medications for COPD, nebulizers, inhalers
Current Illness: Patient had reported on 8/8/2019 having arthritis, leg wounds, COPD, asthma, incontinence of bladder. Resident may also have had blood clots in his legs, per his sister.
Preexisting Conditions: Same as in Item 11.
Allergies: none known known
Diagnostic Lab Data: Unknown by this reporter
CDC 'Split Type':

Write-up: Resident was discovered deceased in his apartment on 1/23/2021. Family had

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=975421&WAYBACKHISTORY=ON


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