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This is VAERS ID 996259

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 996259
VAERS Form:2
Age:72.0
Sex:Male
Location:Texas
Vaccinated:2021-01-19
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-29
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: Fluoxetine HCL, 20 mg, Magnesium Oxide, 400 mg, Atrovastatin/Calcium, 10 mg, Omprazole, 20 mg, Lisinoprilm 2.5.mg, Lyrica, 200mg, Metoprolol Tartrate, 25 mg , Potassium Chloride 20 meq,
Current Illness: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation, OSA on CPAP
Preexisting Conditions: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation,
Allergies: Wellbutrin, Niaspan
Diagnostic Lab Data: Reported by hospital patient was COVID negative. Dr. office did not receive any additional lab information or treatment to her office.
CDC 'Split Type':

Write-up: Unknown. Was informed that the patient went to E/R on 1/25/21 (6 days after receiving vaccine. Died 1/29/21 ( 10 days after receiving vaccine).


Changed on 5/7/2021

VAERS ID: 996259 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Texas
Vaccinated:2021-01-19
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-29
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: Fluoxetine HCL, 20 mg, Magnesium Oxide, 400 mg, Atrovastatin/Calcium, 10 mg, Omprazole, 20 mg, Lisinoprilm 2.5.mg, Lyrica, 200mg, Metoprolol Tartrate, 25 mg , Potassium Chloride 20 meq,
Current Illness: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation, OSA on CPAP
Preexisting Conditions: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation,
Allergies: Wellbutrin, Niaspan Niaspan
Diagnostic Lab Data: Reported by hospital patient was COVID negative. Dr. office did not receive any additional lab information or treatment to her office.
CDC 'Split Type':

Write-up: Unknown. Was informed that the patient went to E/R on 1/25/21 (6 days after receiving vaccine. Died 1/29/21 ( 10 days after receiving vaccine).


Changed on 5/14/2021

VAERS ID: 996259 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Texas
Vaccinated:2021-01-19
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-29
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: Fluoxetine HCL, 20 mg, Magnesium Oxide, 400 mg, Atrovastatin/Calcium, 10 mg, Omprazole, 20 mg, Lisinoprilm 2.5.mg, Lyrica, 200mg, Metoprolol Tartrate, 25 mg , Potassium Chloride 20 meq,
Current Illness: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation, OSA on CPAP
Preexisting Conditions: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation,
Allergies: Wellbutrin, Niaspan Niaspan
Diagnostic Lab Data: Reported by hospital patient was COVID negative. Dr. office did not receive any additional lab information or treatment to her office.
CDC 'Split Type':

Write-up: Unknown. Was informed that the patient went to E/R on 1/25/21 (6 days after receiving vaccine. Died 1/29/21 ( 10 days after receiving vaccine).

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