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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 913143 |
VAERS Form: | 2 |
Age: | 84.0 |
Sex: | Female |
Location: | Texas |
Vaccinated: | 2020-12-29 |
Onset: | 2020-12-29 |
Submitted: | 0000-00-00 |
Entered: | 2020-12-29 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EL0140 / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-29
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 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.
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