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From the 11/26/2021 release of VAERS data:

This is VAERS ID 975735

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Case Details

VAERS ID: 975735 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-01-06
Onset:2021-01-25
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: zinc, acidophylis, albuterol inhaler, vitamin d, mirtazapine, Pepcid, vitamin c, Lasix, magnesium oxide, Depakote, cranberry, melatonin, Zoloft, folic acid, pericolace, simethicone, xarelto, asa, mvi with mineral, synthroid, evista,
Current Illness: COVID 19 01-10-2021 GERD DELUSIONS VASCULAR DEMENTIA WITH BEHAVIORS INSOMNIA CHRONIC DVT LEFT LOWER EXTREMITY HEMOCHROMATOSIS PSYCHOSIS MAJOR DEPRESSIVE DISORDER WITH ANXITY IMPULSE DISORDER VITAMIN DEFICIENCY EDEMA CONSTIPATION HALLUCINATIONS HYPOTHYROIDISM HX OF SKIN CANCER CARPAL TUNNEL LT HAND DYSTHYMIC HTN
Preexisting Conditions: ALZHEIMERS CONTRACTURE OF LEFT HAND
Allergies: Aricept, codeine, hydrocodone, sulfa abx
Diagnostic Lab Data:
CDC Split Type:

Write-up: VACCINE ADMINISTERED 01/06/21 ACQUIRED COVID 19 01/10/21 RESIDENT HAD MULTIPLE CO MORBIDITIES AND WAS DECLINING PRIOR TO VACCINE. RESIDENT EXPIRED ON 01/25/2021


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