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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 936805 |
VAERS Form: | 2 |
Age: | 25.0 |
Sex: | Male |
Location: | Kentucky |
Vaccinated: | 2020-12-22 |
Onset: | 2021-01-11 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-12 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 039K20A / 1 | RA / IM |
Administered by: Private Purchased by: ??
Symptoms: Death, Unresponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-11
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: 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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