This is VAERS ID 937818

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

Vaccin­ation / Manu­facturer (1 vaccine)	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011J20A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions: HTN CAD Stemi with stent placement BPH
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is being reported because of the incident occurring 2 days after the Moderna Covid-19 vaccination. It was reported that the patient expired on 1/9/21, 2 days after receiving the Moderna vaccine. Upon screening of patient prior to administration on 1/7/21, the patient completed paperwork answering NO to the following "Do you currently have any active infections or acute respiratory illness or fever."

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Changed on 11/12/2021

(Changed: Died, Date Died)

Vaccin­ation / Manu­facturer (1 vaccine)	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011J20A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No Yes
   Date died:0000-00-00 2021-01-09
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:
Current Illness:
Preexisting Conditions: HTN CAD Stemi with stent placement BPH
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This is being reported because of the incident occurring 2 days after the Moderna Covid-19 vaccination. It was reported that the patient expired on 1/9/21, 2 days after receiving the Moderna vaccine. Upon screening of patient prior to administration on 1/7/21, the patient completed paperwork answering NO to the following "Do you currently have any active infections or acute respiratory illness or fever."

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