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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 937127 |
VAERS Form: | 2 |
Age: | 91.0 |
Sex: | Male |
Location: | Arkansas |
Vaccinated: | 2020-12-22 |
Onset: | 2020-12-28 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-12 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 025L20A / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, SARS-CoV-2 test positive
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-04
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: Mirtazapine, Fentanyl Patch,
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: The facility had positive cases of COVID when we were able to begin vaccinating residents. Within about a week of vaccination, patient was tested positive for COVID. He was 91 years old and his immune system did not have the time to allow the vaccine to begin working before exposure. His age was a major contributing factor to his death.
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