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This is VAERS ID 977358

History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 977358
VAERS Form:2
Age:99.0
Sex:Male
Location:Florida
Vaccinated:2021-01-08
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 AR / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure congestive, Chest X-ray, Cough, Death, Full blood count, Ultrasound chest, Laboratory test, SARS-CoV-2 test

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, ASA, Paxil, Amlodipine
Current Illness:
Preexisting Conditions: anemia, mild renal insufficiency, hypertension
Allergies: none
Diagnostic Lab Data: CBC, SMA6 Jan 18, Jan20 Covid 19 test Jan 20 Chest X Ray Jan 20 Chest ultrasound Jan 20
CDC 'Split Type':

Write-up: cough congestive heart failure death


Changed on 5/7/2021

VAERS ID: 977358 Before After
VAERS Form:2
Age:99.0
Sex:Male
Location:Florida
Vaccinated:2021-01-08
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 AR / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure congestive, Chest X-ray, Cough, Death, Full blood count, Ultrasound chest, Laboratory test, SARS-CoV-2 test

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, ASA, Paxil, Amlodipine
Current Illness:
Preexisting Conditions: anemia, mild renal insufficiency, hypertension
Allergies: none none
Diagnostic Lab Data: CBC, SMA6 Jan 18, Jan20 Covid 19 test Jan 20 Chest X Ray Jan 20 Chest ultrasound Jan 20
CDC 'Split Type':

Write-up: cough congestive heart failure death


Changed on 5/14/2021

VAERS ID: 977358 Before After
VAERS Form:2
Age:99.0
Sex:Male
Location:Florida
Vaccinated:2021-01-08
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 AR / IM

Administered by: Public      Purchased by: ??
Symptoms: Cardiac failure congestive, Chest X-ray, Cough, Death, Full blood count, Ultrasound chest, Laboratory test, SARS-CoV-2 test

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, ASA, Paxil, Amlodipine
Current Illness:
Preexisting Conditions: anemia, mild renal insufficiency, hypertension
Allergies: none none
Diagnostic Lab Data: CBC, SMA6 Jan 18, Jan20 Covid 19 test Jan 20 Chest X Ray Jan 20 Chest ultrasound Jan 20
CDC 'Split Type':

Write-up: cough congestive heart failure death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=977358&WAYBACKHISTORY=ON

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