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This is VAERS ID 975762

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 975762
VAERS Form:2
Age:57.0
Sex:Female
Location:Idaho
Vaccinated:2021-01-20
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: N/A
Preexisting Conditions: - Hx of aortic dissection - Hx of mitral valve repair - Ascending aortic aneurysm (HCC) - Hearing loss of right year - Scoliosis of thoracolumbar spine - Fatigue - Overweight
Allergies: - Fish containing products - Kale - PCN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt deceased


Changed on 5/7/2021

VAERS ID: 975762 Before After
VAERS Form:2
Age:57.0
Sex:Female
Location:Idaho
Vaccinated:2021-01-20
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: N/A
Preexisting Conditions: - Hx of aortic dissection - Hx of mitral valve repair - Ascending aortic aneurysm (HCC) - Hearing loss of right year - Scoliosis of thoracolumbar spine - Fatigue - Overweight
Allergies: - Fish containing products - Kale - PCN PCN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt deceased


Changed on 5/14/2021

VAERS ID: 975762 Before After
VAERS Form:2
Age:57.0
Sex:Female
Location:Idaho
Vaccinated:2021-01-20
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: N/A
Preexisting Conditions: - Hx of aortic dissection - Hx of mitral valve repair - Ascending aortic aneurysm (HCC) - Hearing loss of right year - Scoliosis of thoracolumbar spine - Fatigue - Overweight
Allergies: - Fish containing products - Kale - PCN PCN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt deceased

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=975762&WAYBACKHISTORY=ON


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