VAERS ID: |
941743 (history) |
Form: |
Version 2.0 |
Age: |
60.0 |
Sex: |
Female |
Location: |
New York |
Vaccinated: | 2021-01-12 |
Onset: | 2021-01-13 |
Days after vaccination: | 1 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-13 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
RA / IM |
Administered by: Other Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Amitiza, Anastrozole, Calcium Carbonate, Levemir, Novolog, Docusate, Fiber Lax, Fluvoxamine Maleate, Gavilax, Glucerna, Ketoconazole, levetiracetam, loratadine, Selenium sulfide lotion, vimpat, vitamin D3, Prolia AS needed medications: fle Current Illness: None Preexisting Conditions: Benign polycythemia, Type II DM, Anxiety, Epilepsy, Blepharitis (bilateral), cataract (not specified), Allergic rhinitis, constipation, scoliosis, osteoporosis, dyspahgia, urinary incontinence, Dermatitis, breast cancer (right breast lumpectomy), history of respiratory infection, DNR AND MOLST were in place at time of death Allergies: No known drug or food allergies Diagnostic Lab Data: None CDC Split Type:
Write-up: This person was found to be deceased on routine rounds during the night, 3am. No symptoms of reaction noted post vaccine. No injection site reaction. No reports of any allergic reaction. |