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This is VAERS ID 976112

History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 976112
VAERS Form:2
Age:81.0
Sex:Female
Location:California
Vaccinated:2021-01-07
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Metoprolol Tartrate Tablet 25 MG BID Norvasc Tablet 10 MG (amLODIPine Besylate) QD Namenda Tablet 5 MG (Memantine HCl) BID Cozaar Tablet 100 MG (Losartan Potassium) QD hydrALAZINE HCl Tablet 25 MG TID Amiodarone HCl Tablet 200 MG QD CloNID
Current Illness: Resident started manifesting loss of appetite and body weakness on January 10,2021 a few days after vaccination. She expired in our facility 1/21/2021.
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING OTHER NONTRAUMATIC 10/28/2020 Principal Diagnosis INTRACRANIAL HEMORRHAGE AFFECTING LEFT DOMINANT SIDE TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE UNSPECIFIED ATRIAL FIBRILLATION ENTIAL (PRIMARY) HYPERTENSION 10/28/2020 Diagnosis 4 Admission HISTORY OF FALLING 10/28/2020 Diagnosis 5 Admission OTHER ABNORMALITIES OF GAIT AND MOBILITY 01/13/2021 Other Diagnosis During Stay COVID-19
Allergies: ASPIRIN PENICILLIN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired on january 21, 2021


Changed on 5/7/2021

VAERS ID: 976112 Before After
VAERS Form:2
Age:81.0
Sex:Female
Location:California
Vaccinated:2021-01-07
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Metoprolol Tartrate Tablet 25 MG BID Norvasc Tablet 10 MG (amLODIPine Besylate) QD Namenda Tablet 5 MG (Memantine HCl) BID Cozaar Tablet 100 MG (Losartan Potassium) QD hydrALAZINE HCl Tablet 25 MG TID Amiodarone HCl Tablet 200 MG QD CloNID
Current Illness: Resident started manifesting loss of appetite and body weakness on January 10,2021 a few days after vaccination. She expired in our facility 1/21/2021.
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING OTHER NONTRAUMATIC 10/28/2020 Principal Diagnosis INTRACRANIAL HEMORRHAGE AFFECTING LEFT DOMINANT SIDE TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE UNSPECIFIED ATRIAL FIBRILLATION ENTIAL (PRIMARY) HYPERTENSION 10/28/2020 Diagnosis 4 Admission HISTORY OF FALLING 10/28/2020 Diagnosis 5 Admission OTHER ABNORMALITIES OF GAIT AND MOBILITY 01/13/2021 Other Diagnosis During Stay COVID-19
Allergies: ASPIRIN PENICILLIN PENICILLIN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired on january 21, 2021


Changed on 5/14/2021

VAERS ID: 976112 Before After
VAERS Form:2
Age:81.0
Sex:Female
Location:California
Vaccinated:2021-01-07
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Metoprolol Tartrate Tablet 25 MG BID Norvasc Tablet 10 MG (amLODIPine Besylate) QD Namenda Tablet 5 MG (Memantine HCl) BID Cozaar Tablet 100 MG (Losartan Potassium) QD hydrALAZINE HCl Tablet 25 MG TID Amiodarone HCl Tablet 200 MG QD CloNID
Current Illness: Resident started manifesting loss of appetite and body weakness on January 10,2021 a few days after vaccination. She expired in our facility 1/21/2021.
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING OTHER NONTRAUMATIC 10/28/2020 Principal Diagnosis INTRACRANIAL HEMORRHAGE AFFECTING LEFT DOMINANT SIDE TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE UNSPECIFIED ATRIAL FIBRILLATION ENTIAL (PRIMARY) HYPERTENSION 10/28/2020 Diagnosis 4 Admission HISTORY OF FALLING 10/28/2020 Diagnosis 5 Admission OTHER ABNORMALITIES OF GAIT AND MOBILITY 01/13/2021 Other Diagnosis During Stay COVID-19
Allergies: ASPIRIN PENICILLIN PENICILLIN
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident expired on january 21, 2021

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