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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 940602 |
VAERS Form: | 2 |
Age: | 83.0 |
Sex: | Male |
Location: | Texas |
Vaccinated: | 2021-01-08 |
Onset: | 2021-01-10 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-13 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 037K209 / 5 | LA / IM |
Administered by: Private Purchased by: ??
Symptoms: Death, Injection site pain, Myocardial infarction, Pain, Syncope
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:0000-00-00
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 attached
Current Illness: None reported
Preexisting Conditions: HTN, Type II DM, High cholesterol
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Patient received vaccine on 1/8/2021. On 1/9/2021 I checked on patient via phone for symptoms or problems and he reported none but mild soreness at injection site. On 1/10/2021 family friend called me to tell me that patient had expired at about 8:00 pm. Patient reportedly complained of "pain" unspecific and collapsed at home. Hospital reportedly told family that it appeared to be a "heart attack".
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