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From the 4/1/2021 release of VAERS data:

Found 2,342 cases where Vaccine is Covid19 and Patient Died

Table

   
AgeCountPercent
< 3 Years20.09%
17-44 Years472.01%
44-65 Years27811.87%
65-75 Years44819.13%
75+ Years1,31856.28%
Unknown24910.63%
TOTAL2,342100%

Case Details

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VAERS ID: 909095 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Colorado  
Vaccinated:2020-12-23
Onset:2020-12-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2020-12-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Foaming at mouth, Pain in extremity, Pallor, Pulse absent, Respiratory arrest, Somnolence, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulosin 0.4mg, Lactobacillus tablet, Nephro-vite tablet 0.8mg, Allopurinol 100mg, ferrous gluconate 324mg, melatonin 6mg, lisinopril 2.5mg, colace 100mg, metamucil powder, aspirin 81mg, amidoarone 200mg, hydrooxyzine 25mg, cholestyramine
Current Illness: End stage renal disease with dependence on renal dialysis, COPD, cirrhosis of the liver, hypokalemia, gout, heart failure, hyperlipidemia, atrial fibrillation.
Preexisting Conditions: Refused dialysis frequently resulting in episodes of hypokalemia and hospitalization, resident dependent on supplemental oxygen. The resident refused to go to dialysis on 12/23/2020 and said he was feeling fine.
Allergies: alprazolam, Lorazepam
Diagnostic Lab Data: None
CDC Split Type:

Write-up: on 12/24/2020 the resident was sleepy and stayed in bed most of the shift. He stated he was doing okay but requested pain medication for his legs at 250PM. At 255AM on 12/25/2020 the resident was observed in bed lying still, pale, eyes half open and foam coming from mouth and unresponsive. He was not breathing and with no pulse


VAERS ID: 910363 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: California  
Vaccinated:2020-12-23
Onset:2020-12-26
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypophagia, Hypotension, Somnolence
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.


VAERS ID: 913143 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Texas  
Vaccinated:2020-12-29
Onset:2020-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin 100mg, Memantine 10mg
Current Illness:
Preexisting Conditions: dementia, aphasia, type 2 DM, iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, MDD
Allergies: codeine, phenobarbital, penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine administered with no immediate adverse reaction at 11:29am. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 1:30pm the resident passed away.


VAERS ID: 913733 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2020-12-29
Onset:2020-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My grandmother died a few hours after receiving the moderna covid vaccine booster 1. While I don?t expect that the events are related, the treating hospital did not acknowledge this and I wanted to be sure a report was made.


VAERS ID: 914604 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated:2020-12-16
Onset:2020-12-20
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Spouse awoke 12/20 and found spouse dead. Client was not transferred to hospital.


VAERS ID: 914621 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Iowa  
Vaccinated:2020-12-22
Onset:2020-12-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J02A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dementia, Fatigue
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Resident in long term care facility for 9+ years Coronary Artery Disease Dementia Hypothyroidism Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident in our long term care facility who received first dose of Moderna COVID-19 Vaccine on 12/22/2020, only documented side effect was mild fatigue after receiving. She passed away on 12/27/2020 of natural causes per report. Has previously been in & out of hospice care, resided in nursing home for 9+ years, elderly with dementia. Due to proximity of vaccination we felt we should report the death, even though it is not believed to be related.


VAERS ID: 914690 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated:2020-12-23
Onset:2020-12-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-26
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC Split Type:

Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020.


VAERS ID: 914805 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon-
Current Illness: none
Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT CODED AND EXPIRED


VAERS ID: 914895 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2020-12-28
Onset:2020-12-30
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Senna Plus, Loperamide, Ondansetron, Acetaminophen, Mucus & Chest Relief cough syrup, Oystershell Calcium Plus D, Vitamin D3, Escitalopram, Bupropion, Hydrocodone/Acetaminophen, Bisacodyl Suppositories
Current Illness: Alzheimer''s Disease, Encephalopathy, Hypertension,Acute Kidney failure, Urine Retention, Recent UTI
Preexisting Conditions: Alzheimer''s Disease, Encephalopathy, Hypertension
Allergies: No known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Injection given on 12/28/20 - no adverse events and no issues yesterday; Death today, 12/30/20, approx.. 2am today (unknown if related - Administrator marked as natural causes)


VAERS ID: 914917 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-19
Onset:2020-12-23
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / UNK - / -

Administered by: Work       Purchased by: ?
Symptoms: Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atenolol, Chlorthalidone, Tamsulosin
Current Illness: None
Preexisting Conditions: hypertension
Allergies: None
Diagnostic Lab Data: Death certificate
CDC Split Type:

Write-up: Death by massive heart attack. Pfizer-BioNTech COVID-19 Vaccine EUA


VAERS ID: 914961 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: per nursing home staff over 14 days post covid
Preexisting Conditions:
Allergies: none listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt passed away with an hour to hour and 1/2 of receiving vaccine. per nursing home staff they did not expect pt to make it many more days. pt was unresponsive in room when shot was given. per nursing home staff pt was 14 + days post covid


VAERS ID: 914994 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 AR / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not known
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was a nursing home pt. pt received first dose of covid vaccine. pt was monitored for 15 minutes after getting shot. staff reported that pt was 15 days post covid. Pt passed away with in 90 minutes of getting vaccine


VAERS ID: 915562 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: none listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt received vaccine at covid clinic on 12/30 at approximately 3:30, pt vomited 4 minutes after receiving shot--dark brown vomit, staff reported pt had vomited night before. Per staff report pt became short of breath between 6 and 7 pm that night. Pt had DNR on file. pt passed away at approximately 10pm. Staff reported pt was 14 + days post covid


VAERS ID: 915682 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Respiratory Disease, Essential Hypertension, Coronary Artery Disease, History of positive COVID 11/17/20
Allergies: No Known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received vaccine per pharmacy at the facility at 5 pm. Approximately 6:45 resident found unresponsive and EMS contacted. Upon EMS arrival at facility, resident went into cardiac arrest, code initiated by EMS and transported to hospital. Resident expired at hospital at approximately 8 pm


VAERS ID: 915880 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Montana  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died within 12 hours of receiving the vaccine.


VAERS ID: 915920 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Ohio  
Vaccinated:2020-12-28
Onset:2020-12-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELO140 / UNK AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Tetanus toxoid
Other Medications: ASA 81, Vitamin D, Vitamin B12, Atorvastatin, Omeprazole, Tylenol, Donepezil, Amlodipine, Coreg, Remeron
Current Illness: Resident was living in an assisted living facility. She fell on 11/24/2020 and was seen in the ER. There, she tested positive for COVID 19. She was admitted to this facility for rehab. She showed a decline after admission and was referred to hospice.
Preexisting Conditions: Vitamin deficiency, hyperlipidemia, hypertension, anemia, dementia, chronic kidney disease III, osteoporosis, history of breast cancer/MI/pulmonary embolism, depression.
Allergies: Tetanus toxoid
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received vaccine in am and expired that afternoon.


VAERS ID: 917117 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Quietapine, Mertazipine, Hydrocodone, Fentanyl
Current Illness: Yes
Preexisting Conditions: Yes
Allergies: None
Diagnostic Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.
CDC Split Type:

Write-up: After vaccination, patient tested positive for COVID-19. Patient was very ill and had numerous chronic health issues prior to vaccination. Facility had a number of patients who had already tested positive for COVID-19. Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk. This was unsuccessful and patient died.


VAERS ID: 917790 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Torsemide, Trazadone, Amitizide, Morphine Sulfate, Fentanyl, Carbidoba-Levodopa, Prednisone, Potassium Chloride, Escalitapram, Incruse Ellipta, Mirtazipane, Clonazepam, Levothyroxine
Current Illness: Patient was a resident of a long term care facility and had numerous chronic conditions prior to vaccination.
Preexisting Conditions: Thyroid disease, chronic elderly conditions.
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: At the time of vaccination, there was an outbreak of residents who had already tested positive for COVID 19 at the nursing home where patient was a resident. About a week later, patient tested positive for COVID 19. She had a number of chronic, underlying health conditions. The vaccine did not have enough time to prevent COVID 19. There is no evidence that the vaccination caused patient''s death. It simply didn''t have time to save her life.


VAERS ID: 917793 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol-Tartrate, Latanoprost, Glipizide, Pravastatin, Metformin, Benaprezil, Potassium-Chloride, Levothyroxine
Current Illness: Diabetes, Thyroid disease
Preexisting Conditions: Diabetes, Thyroid Disease
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Prior to the administration of the COVID 19 vaccine, the nursing home had an outbreak of COVID-19. Patient was vaccinated and about a week later she tested positive for COVID-19. She had underlying thyroid and diabetes disease. She died as a result of COVID-19 and her underlying health conditions and not as a result of the vaccine.


VAERS ID: 918065 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: - Invega Trenza 546mg Q3months - Lithium 300mg BID - Oxybutynin 5mg QID - lipitor 20mg QHS - cogentin 2mg BID - Norvasc 5mg QD - Dyazide Capsule 37.5-25 MG (Triamterene-HCTZ) QD
Current Illness: - covid-19
Preexisting Conditions: - SCHIZOPHRENIA, UNSPECIFIED - ANEMIA, UNSPECIFIED - OVERWEIGHT - OVERACTIVE BLADDER - ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS - HYPOTHYROIDISM DUE TO MEDICAMENTS AND OTHER EXOGENOUS SUBSTANCES - NICOTINE DEPENDENCE, UNSPECIFIED, UNCOMPLICATED - CHRONIC VIRAL HEPATITIS C - UNSPECIFIED AGE-RELATED CATARACT - ESSENTIAL (PRIMARY) HYPERTENSION - CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED - UNSPECIFIED CONVULSIONS - INHALANT ABUSE, UNCOMPLICATED - OTHER SEIZURES
Allergies: - Clozaril - Tegretol
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 1/1/2020: Residents was found unresponsive. Pronounced deceased at 6:02pm


VAERS ID: 918388 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Florida  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuteral Sulfate Amlodipine Carvedilol Ipratropium Levetiracetam Olanzapine Sodium Chloride Symbicort Valproic Acid
Current Illness: No acute illness at time of vaccination. History of: CVA SCPT Dementia Seizure Disorder HTN COPD
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident found unresponsive without pulse, respirations at 04:30 CPR performed, expired at 04:52 by Rescue


VAERS ID: 918418 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyspnoea, Hospice care, Hypoxia, Oxygen saturation decreased, Pulse absent, Respiratory arrest, Respiratory tract congestion
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Mucomyst ASA Benadryl Periactin Colace Ferrous Sulfate Folic Acid Gabapentin Sennosides Albuterol Ipratropium Melatonin MVI Oxycodone Polyethylene Glycol Seroquel Rosuvastatin Valproic Acid Venlafaxine Vitamin C
Current Illness: Hypoxia started on 1/1/2021. History of: Osteomyelitis CVA Pain Pressure Ulcers PVD Hepatitis C COPD HTN HLD Constipation SCPT Anemia Seizure disorder Depression AKA
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data: low oxygen saturation
CDC Split Type:

Write-up: Resident became SOB, congested and hypoxic requiring oxygen, respiratory treatments and suctioning. Stabilized after treatment and for the next 72 hours with oxygen saturations in the 90s. On 1/3/2021 was found without pulse and respirations. Resident was a DNR on Hospice.


VAERS ID: 918487 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Michigan  
Vaccinated:2020-01-02
Onset:2021-01-04
   Days after vaccination:368
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.


VAERS ID: 918518 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2020-12-31
Onset:2020-12-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Cardio-respiratory arrest, Death, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: To be determined
Current Illness: To be determined
Preexisting Conditions: To be determined
Allergies: To be determined
Diagnostic Lab Data: Autopsy being performed
CDC Split Type:

Write-up: syncopal episode - arrested - CPR - death


VAERS ID: 919108 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: New York  
Vaccinated:2020-12-22
Onset:2020-12-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH F10140 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood culture, Culture urine, Full blood count, Malaise, Pyrexia, Urine analysis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: UA. C&S, CBC/Blood culture 1/2/2021
CDC Split Type:

Write-up: Fever, Malaise


VAERS ID: 919537 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-03
Onset:2021-01-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy
Current Illness: Resident had suspected vasovagal episode with drop in O2 saturation.
Preexisting Conditions: ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE RHEUMATOID ARTHRITIS, UNSPECIFIED ANEMIA, UNSPECIFIED HYPOTHYROIDISM, UNSPECIFIED CACHEXIA ESSENTIAL (PRIMARY) HYPERTENSION DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE AGE-RELATED PHYSICAL DEBILITY OTHER CHRONIC PAIN DILATED CARDIOMYOPATHY ERYTHEMATOUS CONDITION, UNSPECIFIED UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE PRIMARY GENERALIZED (OSTEO)ARTHRITIS OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBAR REGION HYPERKALEMIA OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE CERVICALGIA OTHER BIOMECHANICAL LESIONS OF LUMBAR REGION ??? BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE LOCALIZED EDEMA HYPO-OSMOLALITY AND HYPONATREMIA OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE HISTORY OF FALLING WEAKNESS
Allergies: Celebrex and Tramadol
Diagnostic Lab Data: N/A.
CDC Split Type:

Write-up: Resident exhibited no adverse events during 30 minute monitoring following vaccine administration. Resident found without pulse at 1900.


VAERS ID: 920326 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Indiana  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Erythema, Hospice care, Localised oedema, Skin warm
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cetirizine, Lactaid
Current Illness: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Preexisting Conditions: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Allergies: Lactose
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Redness and warmth with edema to right side of neck and under chin. Resident was on Hospice services and expired on 1.1.21


VAERS ID: 920368 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Indiana  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Body temperature increased, Chest X-ray abnormal, Decreased appetite, Dyspnoea, Erythema, Full blood count, Hospice care, Influenza virus test negative, Lung infiltration, Metabolic function test, Respiratory rate increased, Vital functions abnormal, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Atenolol, Colace, Lisinopril, Mirtazapine, Omeprazole, Simvastatin, Vitamin D3
Current Illness: F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Allergies: quinine sulfate
Diagnostic Lab Data: Influenza Swab: 12/30/20-Negative Results CBC: 12/30/20 showed WBC of 14.1 (H) CMP: 12/30/20 showed BUN: 113 (H); Creatinine 2.7 (H) CXR: 12/30/20 showed: Conclusion: A mild left lower lung infiltrate
CDC Split Type:

Write-up: 12/30/2020 07:02 AM Resident noted to have some redness in face and respiration were fast. Resident vital signs were abnormal except blood pressure. Temp at the time was 102.0 F taken temporal. Resident respirations were 22 labored at times. Pulse is 105 and pulse ox 94% on room air. Resident is made comfortable in bed. Notified triage of change in condition also made triage aware of resident receiving Covid vaccination yesterday morning. Resident appetite and fluid consumption has been poor for few days. 12/30/2020 07:32 AM Received order from agency to administer Acetaminophen 650mg suppos rectally due to resident not wanting to swallow anything including fluids, medications and food. This writer administered medication as NP ordered. Will monitor for effectiveness and adverse effects if any. 12/30/2020 08:41 AM Received new orders to obtain Flu swab, obtain CBC and BMP, and Chest Xray all to be obtained today. Notified family of resident having temperature and vital signs excluding b/p that was abnormal. Family was thankful for call and inierated to nurse that family does not want resident sent to hospital. Did educate family on benefits of Hospice services, but family persistant on continued daily care provided by nursing staff. Requests visits if decline continues. Family assured if resident continues to decline, facility will accomandate resident family to be able to be at bedside when time comes to do so. NP ordered IVF and IV Levaquin on 12/31/20. Family chose at that time to sign for Hospice services and not have resident provided with IVF or IV Antibiotics


VAERS ID: 920545 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-01-04
Onset:2021-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abnormal behaviour, Blood pressure abnormal, Fatigue, Limb discomfort, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Hypertension (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf
Current Illness:
Preexisting Conditions: ACUTE POSTHEMORRHAGIC ANEMIA, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH OTHER FORMS OF ANGINA PECTORIS, CARDIAC MURMUR, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA, ESSENTIAL (PRIMARY) HYPERTENSION, FRACTURE OF NASAL BONES, INITIAL ENCOUNTER FOR CLOSED FRACTURE, HYPOXEMIA, PAROXYSMAL ATRIAL FIBRILLATION, PRESENCE OF CARDIAC PACEMAKER, THROMBOCYTOPENIA, UNSPECIFIED CIRRHOSIS OF LIVER, and UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.


VAERS ID: 920815 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-30
Onset:2021-01-04
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: Per employee health records HTN, DM, Breast CA 2016 with radiation, obesity, gastric sleeve 10 years ago, arthritis, plantar fasciitis, ankle tendonitis, DeQuarvains, carpal tunnel, anxiety
Allergies: Lisinpril, Codeine, Latex , environmental (hay fever)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found deceased in her home, unknown cause, 6 days after vaccine.


VAERS ID: 920832 (history)  
Form: Version 2.0  
Age: 104.0  
Sex: Female  
Location: New York  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine 12/30/2020 Screening PCR done 12/31/2020 Symptoms 1/1/2021 COVID test result came back positive 1/2/2021 Deceased 1/4/2021


VAERS ID: 921175 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-01-03
Onset:2021-01-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea
Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea
Allergies: NKA
Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER
CDC Split Type:

Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4,


VAERS ID: 921481 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Ohio  
Vaccinated:2020-12-29
Onset:2021-01-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Lethargy, Rash, Sluggishness
SMQs:, Anaphylactic reaction (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin D3 5000 units qd Furosemide 20mg qd Olanzapine 2.5mg bid
Current Illness: Dementia Chronic PVD
Preexisting Conditions: Dementia PVD
Allergies: No known allergies
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Vaccine given on 12/29/20 by Pharmacy. On 1/1/21, resident became lethargic and sluggish and developed a rash on forearms. He was a Hospice recipient and doctor and Hospice ordered no treatment, just to continue to monitor. When no improvement of codition reported, doctor and Hospice ordered comfort meds (Morphine, Ativan, Levsin). Resident expired on 1/4/2021


VAERS ID: 921547 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain. elevated Temp. Phone Active 05/08/2020 05/08/2020 AmLODIPine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYP
Current Illness: CEREBRAL INFARCTION, UNSPECIFIED(I63.9), LONG TERM (CURRENT) USE OF ASPIRIN(Z79.82), VITAMIN DEFICIENCY, UNSPECIFIED(E56.9), ACUTE KIDNEY FAILURE, UNSPECIFIED(N17.9), HYPERKALEMIA(E87.5), ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA(J96.00), PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED(E78.00), PAIN IN RIGHT FOOT(M79.671), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ACIDOSIS(E87.2), ABNORMAL LEVELS OF OTHER SERUM ENZYMES(R74.8), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), DISORDER OF THYROID, UNSPECIFIED(E07.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS(K21.9), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES(M62.59), COGNITIVE COMMUNICATION DEFICIT(R41.841), UNSPECIFIED LACK OF COORDINATION(R27.9), OTHER DYSPHAGIA (R13.19), OTHER CHRONIC PAIN(G89.29), HYPOTHYROIDISM, UNSPECIFIED(E03.9), DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND (H04.129), METABOLIC ENCEPHALOPATHY(G93.41), UNSPECIFIED CONVULSIONS(R56.9), POLYNEUROPATHY, UNSPECIFIED(G62.9), TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA(E10.319), NASAL CONGESTION(R09.81), BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC(J40), HYPOKALEMIA(E87.6), ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED(D72. 829), OTHER MALAISE(R53.81), CELLULITIS OF RIGHT LOWER LIMB(L03.115), CELLULITIS OF LEFT LOWER LIMB(L03.116), EDEMA, UNSPECIFIED (R60.9), IRON DEFICIENCY ANEMIA, UNSPECIFIED(D50.9), CUTANEOUS ABSCESS, UNSPECIFIED(L02.91), COVID-19(U07.1)
Preexisting Conditions: UNCONTROLLED DIABETES MELLITUS ON INSULIN
Allergies: NKDA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 1/4/2021, RESIDENT RECIEVED VACCINE ON 1/2/20


VAERS ID: 921572 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Fall, Hip fracture, Oxygen saturation decreased, Pain, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away.


VAERS ID: 921667 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: Ohio  
Vaccinated:2020-12-29
Onset:2021-01-03
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: LTCF Pfizer Vaccine clinic conducted 12/29/2020 Vaccine lead received a call indicating that a staff member deceased somewhere between 1/3/2021 and 1/4/2021. Cause of death is unknown, and an autopsy is being performed.


VAERS ID: 921768 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-01-04
Onset:2021-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dizziness, Dyspnoea, Fatigue, Feeling hot, Hot flush, Lethargy, Nausea, Respiratory rate decreased, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: None Known
Diagnostic Lab Data: Autopsy scheduled for 01/07/2021
CDC Split Type:

Write-up: Vaccine received at about 0900 on 01/04/2021 at her place of work, Medical Center, where she was employed as a housekeeper. About one hour after receiving the vaccine she experienced a hot flash, nausea, and feeling like she was going to pass out after she had bent down. Later at about 1500 hours she appeared tired and lethargic, then a short time later, at about 1600 hours, upon arrival to a friends home she complained of feeling hot and having difficulty breathing. She then collapsed, then when medics arrived, she was still breathing slowly then went into cardiac arrest and was unable to be revived.


VAERS ID: 921880 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-02
Onset:2021-01-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Olanzapine, polyethylene glycol, ativan, morphine, senna
Current Illness: was under hospice care
Preexisting Conditions: alzheimers disease, ataxia, HTN, Kidney malignancy history, Prostate cancer history, GERD, sleep apnea, history falls
Allergies: oxycodone
Diagnostic Lab Data:
CDC Split Type:

Write-up: The resident was found deceased a little less than 12 hours following COVID vaccination, and he had had some changes over the last 2 days. He was 96 and had been on hospice care for a little while. Noone noticed any side effects from vaccine after it was given


VAERS ID: 922977 (history)  
Form: Version 1.0  
Age: 71.0  
Sex: Male  
Location: New York  
Vaccinated:2020-12-21
Onset:2020-12-27
   Days after vaccination:6
Submitted: 2020-12-28
   Days after onset:1
Entered: 2021-01-05
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Pyrexia, Respiratory depression, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, RespDepression & COVID positive REMDESIVIR (EUA) 200 mg x1 then 100 mg daily


VAERS ID: 923993 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2020-12-30
Onset:2021-01-02
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: No
Preexisting Conditions: History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma
Allergies: Hay fever
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated Dec 30, 2020. Prime dose of Moderna vaccine. Observed for full 15 minutes post-injection. No complaints when asked during observation. Released. Subsequently, vaccine clinic staff learned from the patient''s supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021. By report from the supervisor, the patient was found dead at his home. The patient''s primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021). Electronic Medical Record without any information since the vaccination.


VAERS ID: 924126 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Michigan  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: resident expired 1/1/2021


VAERS ID: 924186 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Michigan  
Vaccinated:2020-12-30
Onset:2021-01-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 1/3/21


VAERS ID: 924456 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pupil fixed, Regurgitation, Respiratory arrest, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lexapro, famotidine, Namenda, Seroquel, simvastatin, Trazodone; Tamsulosin; Docusate sodium; Polyethylene glycol; Celebrex; Acetaminophen
Current Illness: COVID-19 detected after vaccination; asymptomatic
Preexisting Conditions: Hyperlipidemia; Alzheimer''s disease; Atherosclerotic heart disease of native coronary artery w/o angina pectoris; Osteoarthritis; Major depressive disorder, single episode, unspecified; unspecified severe protein-calorie malnutrition
Allergies: No known allergies
Diagnostic Lab Data: OVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19
CDC Split Type:

Write-up: Patient did not display any obvious signs or symptoms; the vaccination was administered at approximately 10:00 AM and the patient continued throughout her day without any complaints or signs of adverse reaction. Patient was helped to bed by the nursing assistant estimated at around 9:00 PM. The facility received notification from the lab around 11:00 PM that the patient''s COVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19. When the nursing staff went to the room to check on the resident and prepare her to move to a COVID-19 care area the patient was found unresponsive, no movement, no chest rises, noted regurgitated small amount of food to mouth left side, lying on left side. Pupils non reactive.


VAERS ID: 924464 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-05
Onset:2021-01-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Condition aggravated, Haemoptysis, Lung neoplasm malignant
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COPD, lung cancer
Preexisting Conditions: COPD, lung cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: coughing up blood, significant hemoptysis -- $g cardiac arrest. started day after vaccine but likely related to ongoing progression of lung cancer


VAERS ID: 924664 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-02
Onset:2021-01-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O11L20A / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram abnormal, Death, Intracranial aneurysm, Pulmonary oedema, Unresponsive to stimuli, X-ray abnormal
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa
Current Illness: none
Preexisting Conditions: history of stroke, hyperlipidemia, dementia, GERD, and macular degeneration
Allergies: Hydrochlorothiazide
Diagnostic Lab Data: CT scan, X ray 1/5/2021
CDC Split Type:

Write-up: At approximately, 1855, I was alerted by caregiver, resident was not responding. Per caregiver, she was doing her rounds and found resident in bed, unresponsive, mouth open, observed gurgling noises and tongue hanging out of mouth. This primary caregiver observed resident at baseline and ambulating after dinner at approximately, 1800 less than an hour prior to incident. This PCG called 911 for EMS and gave report of incident. Resident was taken to Medical Center Emergency Department. At ER, CT scan and X-ray was performed. Per report from ER RN, CT scan and x-ray revealed an intracranial aneurysm and fluid in the lungs. Per RN, resident was still unresponsive and was admitted to Medical Center for observation and comfort measures. This primary caregiver reported to RN, resident recently received the first dose of COVID-19 vaccine on 1/2/21. Primary caregiver received a call from Castle RN at 0700, resident expired at 0615.


VAERS ID: 925154 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-03
Onset:2021-01-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Avorstatin Aspirin Oxycodone
Current Illness: NONE
Preexisting Conditions: COPD
Allergies: None
Diagnostic Lab Data: Hospital
CDC Split Type:

Write-up: Deceased


VAERS ID: 925264 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2020-12-31
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco 5/325 1 tablet every 6 hours as needed. Warfarin 4mg , 2 tablets orally Monday and Friday Torsemide 100mg, 1/2 tablet orally once a day Sabcubitril-Valsartan 24/26mg 1/4 tablet orally twice a day Gabapentin 300mg, tablet once daily Ca
Current Illness: CHF HTN DM 2 CKD Obesity DDD
Preexisting Conditions: CHF HTN DM 2 CKD Obesity DDD
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: PT was found deceased in his home on 1/5/2021


VAERS ID: 925556 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-30
Onset:2021-01-06
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Acute on chronic heart failure, sepsis
Preexisting Conditions: CAD, CKD, DM type 2, CHF, Hx TIA, Atrial fibrillation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Expired 1/05/2021


VAERS ID: 926269 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-01-04
Onset:2021-01-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Tablet 325 MG, Enulose Solution 10 GM/15ML (Lactulose Encephalopathy), HYDROcodone-Acetaminophen Tablet 5-325 MG, Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide, Potassium Chloride ER Tablet Extended Release 20 ME
Current Illness: Fracture of right superior and inferior pubic rami, fracture of the right sacral alla, and fracture of the L3 vertebral body. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
Preexisting Conditions: Abdominal aortic aneurysm CHRONIC OBSTRUCTIVE PULMONARY DISEASE tobacco abuse, EtOH abuse Ambulatory dysfunction, debility, high risk for falls, deconditioning, ambulatory dysfunction/debility/deconditioning/high fall risk/generalized weakness MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED PERSONAL HISTORY OF MALARIA
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt last seen at 1200 by nurse for ID band check. No visible signs of distress noted. Pt states "I just want to be left alone". 1230 nurse was called to pt room. Pt was noted unresponsive, no pulse and respiration noted. CPR started immediately, at 1239 first shock given. 1245 EMT took over, at 1319 EMT called time of death


VAERS ID: 926462 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Death, Hypoxia
SMQs:, Asthma/bronchospasm (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lorazepam, pantoprazole, miralax, senna plus, carbodopa-levodopa, metoprolol, mirtazipine, quetiapine
Current Illness: dementia, Upper gastrointestinal bleed
Preexisting Conditions: Advanced dementia, Parkinson''s'' disease ,chronic kidney disease, sciatica, hyperlipidemia
Allergies: no known food or medication allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed hypoxia on 1/4/2021 and did not respond to maximal treatment and passed way on 1/5/2021


VAERS ID: 926568 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2020-12-30
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Death
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020


VAERS ID: 926600 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 37K20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Diabetes, renal insufficiency
Preexisting Conditions: Diabetes, renal insufficiency
Allergies: Penicillin, ibuprofen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient did not report any signs or symptoms of adverse reaction to vaccine. Patient suffered from several comorbidities (diabetes and renal insufficiency). Patient reported not feeling well 01/06/2021 and passed away that day.


VAERS ID: 926797 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2020-12-31
Onset:2021-01-01
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: This is a 93 year old with significant heart issues?EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine
Preexisting Conditions: Heart disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: had a vaccination on 12/31/2020 late morning passed away early morning 01/01/2020. This is a 93 year old with significant heart issues. EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine.


VAERS ID: 927189 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: stroke
Preexisting Conditions: hypertension, atrial fibrillation, atherosclerosis,
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated at 11am and was found at the facility in his room deceased at approximately 3:00pm. Nurse did not have cause of death


VAERS ID: 927260 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2020-12-28
Onset:2021-01-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid increased, Bradycardia, Cardiac arrest, Computerised tomogram head normal, Death, Heart sounds abnormal, Pulse absent, Respiration abnormal, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met
Current Illness: Digestive Surgery for bowel obstruction
Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer,
Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids
Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative
CDC Split Type:

Write-up: No adverse effects noted after vaccination. Patient with cardiac history was found unresponsive at 16:45 on 1/6/21. Abnormal breathing patterns, eyes partially closed SPO2 was 41%, pulseless with no cardiac sounds upon auscultation. CPR and pulse was regained and patient was breathing. Patient sent to Hospital ER were she remained in an unstable condition had multiple cardiac arrest and severe bradycardia and in the end the hospital was unable to bring her back.


VAERS ID: 928062 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid increased, Cardiac arrest, Death, Endotracheal intubation, Hypotension, Hypoxia, Laboratory test, Lethargy, Liver function test, Lung infiltration, Pancytopenia, Pulmonary congestion, Pulmonary imaging procedure abnormal, Troponin, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ACETAMINOPHEN CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA ER CITALOPRAM HBR DONEPEZIL HCL EUCERIN FINASTERIDE FLOMAX LATANOPROST OMEPRAZOLE QUETIAPINE FUMARATE QUETIAPINE FUMARATE SENNA LAX
Current Illness: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Preexisting Conditions: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Allergies: angioedema due to ACE and ARB meds
Diagnostic Lab Data: Pancytopenia, elevated lactate, troponin, LFTs. Left mid lung infiltrate and pulmonary vascular congestion.
CDC Split Type:

Write-up: vomiting later on 01/05/21. Lethargy and hypoxia in pm of 01/06/21. Hypotension am of 01/07/21. Hospitalized, intubated, cardiac arrest, died 01/07/21.


VAERS ID: 928513 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-05
Onset:2021-01-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone Hcl, Carvedilol, Ferrous sulfate, Eliquis (cont)
Current Illness: Atrial fibrillation, Anemia, 1st degree AV block, CDK stage 4,
Preexisting Conditions: CDK stage 4, Atrial fibrillation, 1st degree AV block, Patient was under hospice care
Allergies: Aldactone, contrast dye
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away in her sleep


VAERS ID: 928933 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Iowa  
Vaccinated:2020-12-23
Onset:2021-01-08
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Resuscitation
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had been diagnosed with COVID-19 on Dec. 11th, 2020. Symptoms were thought to have started on 12/5/2020. Received Moderna vaccine on 12/23. Unexpected death on 1/8/2021. Resuscitation attempts unsuccessful


VAERS ID: 929359 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-06
Onset:2021-01-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Breath sounds abnormal, Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Preexisting Conditions: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 3:07 pm lung sounds diminished oxygen sats 68%, oxygen applied Oxygen sats remained low for next 36 hours ( patient on Hospice care ) expired 6:22 am 1-8-21


VAERS ID: 929764 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Washington  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorthiazide (by record, not confirmed)
Current Illness:
Preexisting Conditions: Hypertension, sleep apnea, obesity. based on medical record
Allergies: no known allergies recorded in medical record
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient was found deceased at home about 24 hours after immunization. Date of Death:: 12/29/2020; estimated time of death 6:00pm


VAERS ID: 929997 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-04
Onset:2021-01-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysphagia, Feeding disorder, Lethargy, Mobility decreased, Speech disorder
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID
Current Illness: none acute
Preexisting Conditions: He was on hospice for about the last 1 month for CHF (EF 20-25%) and renal failure (creat 3-4). He was on hospice but was up and around and able to eat and take pills. The day after he had his injection, he was very lethargic and only mumbled. Was not able to take meds or eat. He was on hospice, so did not want work-up or treatment. He passed away on 1/7 am. We don''t know if it was a coincidence that he died or if the vaccine caused him to deteriorate more quickly.
Allergies: Losartan, lisinopril, metoprolol
Diagnostic Lab Data: He did not have testing at that point because he was on Hospice.
CDC Split Type:

Write-up: Patient received vaccine on 1/4/2021. He was in Hospice for CHF and renal failure, but was able to get up in his wheelchair and eat and take medications and talk. On 1/5/2021 am, he was noted to be very lethargic an could only mumble, could not swallow. No localizing neurologic findings. He was too lethargic to get up in chair.


VAERS ID: 930154 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type: VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.


VAERS ID: 930431 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Connecticut  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac disorder, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Enteric Coded Aspirin, Atenolol, Centrum Silver, Citrical, Levothyroxin, Lisinipril, Phillips Colon Health Caps, Vitamin D
Current Illness: none
Preexisting Conditions: Aortic Stenosis, Status post Tavr procedure, Hypothyroidism, Hypertension, Thoracogenic Scoliosis, Polymyalgia Rheumatica, Heart Valve Replacement, Hyperparathyroidism
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Cardiac event, 2 days after vaccination, patient expired.


VAERS ID: 930466 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Myocardial infarction, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, shortness of breath and chest pain that resulted in a heart attack a few hours after vaccination


VAERS ID: 930487 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: calcium-D tablet, cholecalciferol, fish oil, melatonin, tylenol,
Current Illness: na
Preexisting Conditions: bph, apraxia, , dysphagia, muscle weakness, alzheimers disease
Allergies: cephalexin
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Medical docter state patient has a acute cardiac attack


VAERS ID: 930876 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, X-ray with contrast
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Prostate Cancer
Allergies:
Diagnostic Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.
CDC Split Type:

Write-up: Death


VAERS ID: 958443 (history)  
Form: Version 2.0  
Age: 1.08  
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-24
Onset:2020-12-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Completed suicide, Death, Gun shot wound
SMQs:, Suicide/self-injury (narrow), Accidents and injuries (narrow), Hostility/aggression (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death by suicide Narrative: death by suicide; 12/26/20, self inflicted gun shot wound; found deceased by family member


VAERS ID: 930910 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.


VAERS ID: 930912 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Diarrhoea
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2001-01-08
   Days after onset: 7305
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diarrhea followed by death 24 hrs after vaccination


VAERS ID: 951518 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 2021-01-05
   Days after onset:1
Entered: 2021-01-09
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death, SARS-CoV-2 test negative, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Specimen: NASOPHARYNX. Specimen Collection Date: Dec 29, 2020@09:45 Test name Result units Ref. range Site Code COVID-19 (M2000) Not Detected
CDC Split Type:

Write-up: Narrative: Patient with severe aphasia and only able to say "hey, hey, hey" or "uh huh" or shake his head no as a way to communicate. Patient previously able to ambulate with significant limp and hyperextension of right knee, but mostly wheelchair bound over last several years as he had had a slow and steady decline in overall health and mobility. Patient developed aggressive behavior of shouting "hey" and grabbing of groin in 2016. This was worked up with CT scans, labs, referral to urology, neurology, and referrals to psychiatry. The exact etiology of this action was never able to be affirmed, but thought to be more psychiatrically related. It improved significantly with addition of antipsychotics, worsened when antipsychotics were reduced, and improved again with addition of injectable antipsychotic on 12-10-2020.Patient suffered from falls on occasion given his significantly impaired physical mobility. His last documented fall was 8-31-2019. Patient began utilizing wheelchair most of time following that fall. No significant injuries noted in documentation of the falls. In the last 3 months, patient would often refuse medications. He would sometimes indicate that they would cause dizziness, and other times he would simply refuse. We attempted to hide medications in his food/fluid (with wife''s blessing) and when he detected this he would occasionally refuse to eat. Patient previously on DOAC. After pharmacy review in 12/2020 it was recommended to discontinue this as no clear indication to continue use. He was high fall risk and would often refuse this medication as well since 10/2020. Noted to be in NSR on EKGs and decision made to discontinue the DOAC. Patient had no evidence of adverse effects noted after vaccination on December 28th. Patient seen by provider on the morning of his death (1/4/2021) with no noticeable significant change in health condition. Temperature 36.8Con January 4th at 19:45. During routine bedtime cares, patient suddenly collapsed and death was pronounced January 4, 2021 at 20:05. Autopsy was requested from next of kin and no autopsy was granted. Symptoms: & DEATH Treatment:


VAERS ID: 951519 (history)  
Form: Version 1.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 2021-01-06
   Days after onset:1
Entered: 2021-01-09
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Palpitations, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Symptoms: Palpitations & Syncope Treatment: EPINEPHRINE 1 MG ONCE ,EPINEPHRINE 1 MG ONCE ,SODIUM BICARBONATE 50 ML ONCE


VAERS ID: 956903 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-22
Onset:2020-12-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asymptomatic COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: mi Narrative: patient with asymptomatic covid 19, covid positive 12/10/2020.


VAERS ID: 956966 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-25
Onset:2020-12-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Body temperature increased, Complication associated with device, Cough, Dyspnoea, Hypoxia, Secretion discharge
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: hypoxia, secretions,cough, dyspnea Narrative: ALS patient on hospice with ongoing history of aspiration pna, receiving tube feeds. Developed incr in secretions, hypoxeia, temp and with recently noted clogged feeding tube.


VAERS ID: 964629 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-17
Onset:2020-12-27
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Terminal state
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death - Hospice patient with metastatic CA admitted to facility and received vaccine during stay. No adverse sequelae noted from vaccine administration, but reporting as required because pt died 7 days later. Narrative: Reporting this event because patient died 7 days after receiving vaccine in the facility where he was in hospice care for metastatic cancer. Vaccine was administered by protocol without complications. The patient had been asked and denied any prior severe reaction to this vaccine or its components and gave permission to receive it. No vaccine adverse sequelae were documented after the immunization as monitored for 15 minutes nor in facility notes for 7 days after the immunization. The patient''s death was felt to be due to underlying terminal illness.


VAERS ID: 964636 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-17
Onset:2020-12-22
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt on hospice in facility for severe cardiomyopathy unable to perform interventions received vaccine without adverse sequelae died 5 days later. Reporting as required. Narrative: Reporting as required patient death 5 days after immunization with Pfizer vaccine. However, no adverse sequelae were noted to the vaccine in the 15minute observation period, nor in the days following the immunization related to the vaccine. The patient denied any prior severe reaction to this vaccine or its components, and the patient gave verbal consent to receive the vaccine. Patient had been in the facility on hospice since 11/18/20 for severe decompensated HF and newly diagnosed cardiomyopathy, unable to perform interventions, also LE ischemic wounds with very poor potential to heal due to advanced PVD.


VAERS ID: 932346 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 2 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Headache, Pyrexia, Respiratory arrest, Resuscitation
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: none known
Preexisting Conditions: hypertension, hyperlipidemia.
Allergies: Statin - muscle aches
Diagnostic Lab Data: autopsy pending
CDC Split Type:

Write-up: 1/7-21 - Received second dose of pfizer covid-19 vaccine 1/8/21 - Fever, dizziness, headache 1/10/21 0250 was found not breathing. EMS performed CPR and patient deceased


VAERS ID: 932787 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-08
Onset:2021-01-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? Yes
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CRANBERRY, PROZAC, NEUROTIN PERCOCET, IMMODIUM, SYNTHROID, LINZESS, LIPITOR, MELATONIN METFORMIN, PROTONIX PLAVIX, PROAIR, ropinirole, PROAIR SYMBICORT, THIAMINE TYLENOL VIT C VOLTAREN. ZANAX, ZOFRAN
Current Illness: PNEUMONIA
Preexisting Conditions: DEPRESSION CHRONIC LUNG ANEMIA
Allergies: TRAMADOL, methocarbamol
Diagnostic Lab Data: NONE AT TIME OF REPORTING, TALK OF AN AUTOPSY
CDC Split Type:

Write-up: RECIEVED VACCINE 1/8/21 EXPIRED UNEXPECTED 1/10/21, NO ADVERSE REACTIONS NOTED


VAERS ID: 932898 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2020-12-17
Onset:2020-12-23
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac disorder, Intensive care, Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Atorvastatin, Xarelto, Aspirin (These were medications listed with our office in 2019. Unknown if this patient was still taking at time of vaccination).
Current Illness:
Preexisting Conditions: High blood pressure. Congenital unicuspid aortic valve s/p aortic valve replacement 2001 & 2011. Pacemaker placement 2011. Melanoma
Allergies: None known.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: The patient had an apparent cardiac arrest on 12/23/20 and was admitted to the ICU. He was taken off of life support on 12/30/20. He had known cardiac disease.


VAERS ID: 933090 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 2 AR / SYR

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient died, I have a copy of his vaccination card


VAERS ID: 964653 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Decreased appetite, Fatigue, General physical health deterioration, Loss of consciousness, Nausea, Pneumonia aspiration, Pyrexia, Respiratory distress
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient''s temperature log: 12-15-20 08:38:00 97.6 O 12-15-20 16:38:00 97.8 O 12-16-20 08:43:00 97.9 O 12-16-20 11:25:00 98.3 O 12-16-20 16:50:18 98.2 12-17-20 06:22:47 98.1 12-17-20 08:27:00 98.1 O 12-17-20 14:20:00 98.4 O 12-17-20 16:34:00 97.5 O 12-18-20 06:14:00 97.3 Ax 12-18-20 08:05:00 97.5 O 12-18-20 17:30:00 97.5 O 12-19-20 05:35:00 98.1 O 12-19-20 08:21:00 98.4 O 12-19-20 16:32:00 98.4 O 12-20-20 08:27:00 98 O 12-20-20 16:58:39 97.6 12-21-20 08:20:00 98 O 12-21-20 16:34:00 98.8 O 12-22-20 05:44:00 98.2 O 12-22-20 08:58:00 97.7 O 12-22-20 16:39:00 97.5 O 12-23-20 08:12:00 97.5 O 12-23-20 16:56:26 98.1 12-24-20 08:18:00 98.2 O 12-24-20 16:37:00 98.4 O 12-25-20 05:35:00 98 O 12-25-20 08:17:00 97.6 O 12-26-20 05:54:00 98.2 O 12-26-20 08:30:01 97.7 12-26-20 16:16:00 97.5 O 12-27-20 06:23:34 97.9 12-27-20 08:40:37 97.6 O 12-27-20 16:23:00 97.4 O 12-28-20 07:52:00 98.3 O 12-28-20 17:57:31 97.7 12-29-20 05:23:14 98.3 12-29-20 08:43:00 98.4 O 12-29-20 16:44:00 98.6 O 12-30-20 05:54:15 97.4 12-30-20 08:24:00 97.6 O 12-30-20 21:16:00 98.3 O 12-31-20 06:04:02 97.9 12-31-20 08:26:00 97.5 Ax 12-31-20 19:00:00 97.9 O 01-01-21 06:22:09 98.3 01-01-21 08:04:00 98.7 O 01-01-21 16:15:00 99.1 O 01-01-21 17:01:00 97.1 O 01-02-21 06:19:09 98 01-02-21 08:22:00 98.3 O 01-02-21 16:05:00 98 O 01-03-21 06:11:00 97.2 O 01-03-21 08:20:00 98.2 O 01-03-21 16:03:00 97.7 O 01-04-21 05:42:00 97.8 O 01-04-21 08:25:00 98.1 O 01-04-21 18:04:00 97.9 O 01-05-21 05:27:21 98 01-05-21 08:50:00 98.4 O 01-05-21 08:53:22 98.4 01-05-21 16:53:01 98.6 01-06-21 06:03:04 98.1 01-06-21 08:13:00 97.8 O 01-06-21 16:59:00 98 O ***01-07-21 05:35:15 102.9*** 01-07-21 08:15:00 98.5
CDC Split Type:

Write-up: loss of consciousness; respiratory distress Narrative: Patient tolerated his 1st dose of the COVID-19 vaccine well, on 12/16/2020, and received his 2nd dose on 1/6/2021. Patient had some mild clinical decline the past few days prior to 2nd vaccination, with a decreased appetite and some increased fatigue per nursing report, but no significant changes. He experienced nausea on the evening of 1/6/21, which was effectively managed, but by early morning he spiked a fever of 102.9 with a sat of 86.1%. He continued to deteriorate from that point on and died 1/7/21 @13:20. Clinically, the presentation was most consistent with an aspiration pneumonia.


VAERS ID: 933578 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-08
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021


VAERS ID: 933739 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain death, Bronchial secretion retention, Cardio-respiratory arrest, Death, Dyspnoea, Electroencephalogram abnormal, Intensive care, Mechanical ventilation, Resuscitation, SARS-CoV-2 test negative, Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Diazepam, Doxepin HCL, Duloxetine, Juven POW, Lamotri Levothyroxin, Loratadine, Melatonin, Mucus Relief, Olanzapine, Prazosin HCL, Pregabalin,
Current Illness: Recent g-tube placement, Several hospitalizations over the pas few months due to low Oxygen Levels.
Preexisting Conditions: Major depression, borderline personality disorder, Cerebral Palsy, History of dissected left carotid artery
Allergies: Penicillin
Diagnostic Lab Data: COVID-19 test administered - 1/9/2021 - Negative 2 EEGs were performed on 1/9/2021 and both indicated she had not brain activity
CDC Split Type:

Write-up: Staff member checked on her at 3am and patient stated that she felt like she couldn''t breathe. 911 was called and taken to the hospital. While in the ambulance, patient coded. Patient was given CPR and "brought back". Once at the hospital, patient was placed on a ventilator and efforts were made to contact the guardian for end of life decisions. Two EEGs were given to determine that patient had no brain activity. Guardian, made the decision to end all life saving measures. Patient was taken off the ventilator on 1/9/2021 and passed away at 1:30am on 1/10/2021. The initial indication from the ICU doctor was the patient had a mucus plug that she couldn''t clear.


VAERS ID: 933846 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-01-02
Onset:2021-01-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 077L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Back pain, Cardiac disorder, Death, Dizziness, Pain in extremity
SMQs:, Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: MACULAR DEGENERATION 10 YEARS OR MORE
Preexisting Conditions: NONE
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1-2-2021 10:30 PM Complained Right arm/back hurt - took Tylenol 1-3-2021 Complained Right arm hurt, dizzy 1-4-2021 Felt better - did laundry, daughter found her deceased at 3:30 pm. Dr. at hospital said it was "cardiac event" according to death certificate.


VAERS ID: 934050 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Fall, Posture abnormal, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient was a resident in Group Home Current Medications Treatments/PRN Medications: Start Date: 04/02/14: Benztropine 2mg tab BID (8-8) 02/27/15: Midodrine (Proamatine) 5mg tab TID (8-12-8) 12/30/15: Cetirizine 10mg tab daily @8am 1
Current Illness: No Acute Illnesses
Preexisting Conditions: Diagnosis: - Impulse Control Disorder - Epilepsy - Tardive Dyskinesia - Ulcerative Proctitis and Colitis - Mental Retardation (mod) - Hammer toes (bilat.) - Dermatitis (scalp/torso) - Seborrheic keratosis of left armpit - Major Depression - Infantile Meningitis - History of Squamous Cell Carcinoma (L arm)
Allergies: Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Staff reported that patient was found Friday morning (Jan 8) sitting at a table with his head tilted forward and unresponsive to verbal or physical stimuli. Staff lowered patient to floor and started CPR. EMS was called and continued CPR at scene, however they were not able to revive patient. Patient was pronounced dead at the scene. Staff written statements following the death of patient show that he had a fall about 1 hr. prior. It is unknown if this fall contributed to patient''s death. An autopsy has been requested.


VAERS ID: 934059 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myocardial infarction, Death
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: tramadol, calcium, Tylenol, lisinopril, Mucinex, MVI, namenda
Current Illness: Had Covid 19 infection in November recovered, had spinal stenosis with leg weakness chronic
Preexisting Conditions:
Allergies: anastrozole
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute anterior MI with death


VAERS ID: 934263 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Malaise, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Again, I cannot confirm the results of any test, i.e., COVID or other, because the patient is independent and sought care independent of the center.
CDC Split Type:

Write-up: The resident resides in an independent living facility/apartment. The reporter at the center was informed by his daughter he was not feeling well on 1/1/2021 (specific symptoms could not be ascertained). He reportedly went to be COVID tested on 1/1/2020 and observed to be deceased in his apartment on 1/2/2020. I do not have confirmation of his COVID results, although the reporter indicates his daughter reports his test was positive.


VAERS ID: 934373 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-01-09
Onset:2021-01-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pulse absent, Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Husband only knew that she took several medications.
Current Illness: Newly diagnosed heart murmur the week prior by PCP. Was referred to her cardiologist.
Preexisting Conditions: She did have open heart surgery in 2013. She last saw her cardiologist 4 months ago, and she did a phone consult with him a week or so ago.
Allergies: PCN & Sulfa drugs
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient went to bed around 11pm on Saturday PM and sometime between then and 1:30am on Sunday morning got up and went into the living room without waking up her husband (which is normal). At 1:30am, the husband got up to use the restroom and she was out of bed then, but the husband did not know if she was having any problems at this time. When he got up at 7:45am, she was in the recliner and did not move or anything, which is normal for her. At 8:45am, the husband went back into the living room and tried to wake his wife and that is when he noticed there was no pulse and he called 9-1-1 at this time. EMS got on scene and did CPR for 30 mins and she was pronounced dead at 9:21am.


VAERS ID: 934507 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-03
Onset:2021-01-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coumadin 2mg po Sat-Mon-Tues-Thurs Coumadin 1mg po Fri Sun APAP 650 mg po PRN pain or temp above 101 Amiodarone 200mg po daily Ativan 0.5mg po PRN anxiety Claritin 10mg po daily Gabapentin 100mg po BID PRN phantom pain Miralax 17Gm po with
Current Illness: No other illness prior to vaccination or within the month prior
Preexisting Conditions: Covid 19 Recovered spring 2020 Chronic stage 5 kidney disease with dialysis 3 times weekly Chronic diastolic congestive heart failure Chronic A-fib Diabetes Mellitus with other circulatory complications Hypertension Right and Left Below the knee amputations
Allergies: KNDA KNFA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident died suddenly and expectantly on 01/05/2021


VAERS ID: 934539 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA D12L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Blood test, Culture tissue specimen, Death, Toxicologic test, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Singulair, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,
Current Illness: Cellulitis of left lower limb (12/2020)
Preexisting Conditions: Hypertension
Allergies: No known allergies
Diagnostic Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.
CDC Split Type:

Write-up: Patient received COVID-19 (Moderna) vaccine from the Health Department on afternoon of January 8, 2021 and went to sleep approximately 2300 that night. Was found unresponsive in bed the following morning and pronounced dead at 1336 on January 9, 2021


VAERS ID: 934966 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, Pyrexia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Alzheimer''s disease
Allergies:
Diagnostic Lab Data: Test Date: 20201225; Test Name: COVID-19; Test Result: Negative ; Test Date: 20210104; Test Name: COVID-19; Test Result: Positive
CDC Split Type: USPFIZER INC2021011125

Write-up: COVID-19; COVID-19; Pneumonia; respiratory failure; This is a spontaneous report from a contactable consumer. An 80-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 02Jan2021 for COVID-19 immunization. Medical history included Alzheimer''s and others. No known allergies. Concomitant medications included unspecified medications. The reporter''s mother in law was tested for COVID-19 at a nursing facility on 25Dec2020 and she was negative. On 02Jan2021, she received the first dose of Pfizer vaccine. On 04Jan2020, she developed a high fever, needed oxygen and was positive for COVID-19. Date of death was 04Jan2021. The cause of her death was listed as pneumonia, respiratory failure and COVID-19. No autopsy performed. No treatment received. No one knew if the vaccination contributed to her death. It was hard to know if her death was due to the administration of the vaccine or it exacerbated the COVID19 symptoms which led to her death. Since this was unknown, it could have been a possibility. The reporter wanted to give us this information because we might want to consider having high risk population, patients with underlying conditions, older population tested for COVID-19 prior to the vaccination, as this is not currently a recommendation or a requirement. All is very new and they are all learning so the reporter wanted to share this information with us. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. There are medications the patient received within 2 weeks of vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has been tested for COVID-19. The outcome of the events was fatal. Information about Lot/Batch has been requested.; Sender''s Comments: The association between the fatal event lack of effect (pneumonia, respiratory failure and COVID-19) with BNT162b2 can not be fully excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.; Reported Cause(s) of Death: Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19


VAERS ID: 934968 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-04
Onset:2021-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Agitation, Death, Decreased appetite, Dehydration, Dyspnoea, Malaise, Pallor, Restlessness, Tachyphrenia, Unresponsive to stimuli, Vaccination complication, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ; ; ;
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure high; Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021011383

Write-up: he passed away; not responsive; mind just seemed like it was racing; body was hyper dried; Restless; not feeling well; ate a bit but not much; kind of pale; Agitated; Vomiting; trouble in breathing; This is a spontaneous report from a contactable consumer (brother of the patient). A 54-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, on 04Jan2021 (at the age of 54-years-old) as a single dose for COVID-19 immunization. Medical history included diabetes and high blood pressure. Concomitant medications included metformin (MANUFACTURER UNKNOWN) taken for diabetes, glimepiride (MANUFACTURER UNKNOWN) taken for diabetes, lisinopril (MANUFACTURER UNKNOWN), and amlodipine (MANUFACTURER UNKNOWN). The patient experienced not feeling well, ate a bit but not much, kind of pale, vomiting, trouble in breathing, and agitated on 04Jan2021; body was hyper dried and restless on 05Jan2021; mind just seemed like it was racing on 06Jan2021; and not responsive and he passed away on 06Jan2021 at 10:15 (reported as: around 10:15 AM). The clinical course was reported as follows: The patient received the vaccine on 04Jan2021, after which he started not feeling well. He went right home and went to bed. He woke up and ate a bit but not much and then was kind of pale. The patient then started to vomit, which continued throughout the night. He was having trouble in breathing. Emergency services were called, and they took his vitals and said that everything was okay, but he was very agitated; reported as not like this prior to the vaccine. The patient was taken to urgent care where they gave him an unspecified steroid shot and unspecified medication for vomiting. The patient was told he was probably having a reaction to the vaccine, but he was just dried up. The patient continued to vomit throughout the day and then he was very agitated again and would fall asleep for may be 15-20 minutes. When the patient woke up, he was very restless (reported as: his body was just amped up and could not calm down). The patient calmed down just a little bit in the evening. When the patient was awoken at 6:00 AM in the morning, he was still agitated. The patient stated that he couldn''t breathe, and his mind was racing. The patient''s other brother went to him and he was not responsive, and he passed away on 06Jan2021 around 10:15 AM. It was reported that none of the symptoms occurred until the patient received the vaccine. Therapeutic measures were taken as a result of vomiting as aforementioned. The clinical outcome of all of the events was unknown; not responsive was not recovered, the patient died on 06Jan2021. The cause of death was unknown (reported as: not known by reporter). An autopsy was not performed. The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: not responsive and he passed away


VAERS ID: 935222 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-30
Onset:2021-01-07
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Oxybutynin Chloride, Lasix 80mg, hydyralazine 50mg, amlodipine 10mg, amitriptyline 10mg, ASA, Klor-Con 20meq, Tylenol, allopurinol 100mg, Vit D3, turmeric 400mg, Lipitor 80mg, gabapentin 100mg, baclofen 5mg, candesartan 32mg, insulin lispro
Current Illness: No acute illnesses
Preexisting Conditions: Diabetes, CKD, CHF, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was reported to be deceased at home by law enforcement on 1/7/21


VAERS ID: 935343 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-01-08
Onset:2021-01-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: This resident had covid a couple months ago. she had a bad heart and also dementia. I do not believe it was the vaccine that killed her. I was instructed by EMS to report because the date of vaccination was three days ago.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: There were no adverse reactions. Resident Died, she had a history of issues with her health prior to the vaccine.


VAERS ID: 935350 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Texas  
Vaccinated:2020-12-31
Onset:2021-01-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021


VAERS ID: 935511 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MODERNA / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known of
Preexisting Conditions: history of vaginal adenocarcinoma- removed with surgery in 2019
Allergies: latex (skin reaction)
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received the 1st dose of Moderna and was found deceased in her home the next day.


VAERS ID: 935767 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-10
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: IDK
Current Illness: Pneumomia
Preexisting Conditions: Dementia
Allergies: IDK
Diagnostic Lab Data: She had tested NEGATIVE for Covid per Doc Win he told us on Sunday.
CDC Split Type:

Write-up: My mother was given Pfizer vaccine on Thursday and she died 3 days later yesterday on Sunday!!!


VAERS ID: 935815 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Difficulty breathing, death.


VAERS ID: 936043 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-04
Onset:2021-01-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atorvastatin,senna,MultiVitamin,Metamucil,metformin,Levothyroxine
Current Illness: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Preexisting Conditions: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Allergies: PENICILLINS
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT 1ST DOSE OF MODERNA VACCINE ADMINISTERED ON 01/04/2021 AT 8:30PM, RESIDENT FOUND UNRESPONSIVE ON 01/05/2021.


VAERS ID: 936738 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Adenovirus test, Blood pressure immeasurable, Bordetella test negative, Chlamydia test negative, Death, Enterovirus test negative, Human metapneumovirus test, Human rhinovirus test, Hypopnoea, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Intensive care, Loss of consciousness, Mycoplasma test negative, Polymerase chain reaction, Radial pulse abnormal, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Staphylococcus test negative, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: RSV, Bordetella Parapertussis, Bordetella Pertussis, Chlamydia pneumoniae, mycoplasma pneumoniae, Coronavirus, Adenovirus, Human metapneumovirus, human rhino/entero virus, influenza A/B, parainfluenza PCRs negative (NOT DETECTED) per 12/27/20 results COVID-19 PCR, Influenza A/B, and RSV PCRs negative (NOT DETECTED) per 1/4/21 results MRSA SURVL NARES DNA negative (NOT DETECTED) per 12/27/20, 12/28/20, & 1/5/21 results
CDC Split Type:

Write-up: loss of consciousness Narrative: Patient received COVID-19 vaccine dose #1 on 1/6/21 w/o complications. Per 1/6/21- 1/9/21 nursing notes, patient did not experience any injection site reactions, denied pain or tenderness at injection site, no dizziness, no n/v, remained afebrile. Around 1/9/21 @1810, patient became acutely nonresponsive after being helped to the edge of bed. Per nurses, he was previously awake/alert, talking and asymptomatic. Patient is DNR/DNI but facility rapid response emergency team called d/t patient''s sudden change of condition. Emergency team helped patient into lying position. Per 1/9/21 ICU emergency team note, patient appeared comfortable w/ no palpable radial pulse and had minimal shallow agonal breathing. Pulse ox 94%, HR in 60s per machine. BP unmeasurably low by BP cuffx3. Resident passed at 18:20 pm.


VAERS ID: 936805 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-22
Onset:2021-01-11
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See Continuation Field
Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine
Preexisting Conditions: Septal defect (heart), chronic sinusitis
Allergies: Ceftriaxone
Diagnostic Lab Data: None associated.
CDC Split Type:

Write-up: Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21.


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