This is VAERS ID 914621

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History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

Vaccin­ation / Manu­facturer (1 vaccine)	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011J02A / 1	RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dementia, Fatigue

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-27
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: None
Preexisting Conditions: Resident in long term care facility for 9+ years Coronary Artery Disease Dementia Hypothyroidism Hypertension
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident in our long term care facility who received first dose of Moderna COVID-19 Vaccine on 12/22/2020, only documented side effect was mild fatigue after receiving. She passed away on 12/27/2020 of natural causes per report. Has previously been in & out of hospice care, resided in nursing home for 9+ years, elderly with dementia. Due to proximity of vaccination we felt we should report the death, even though it is not believed to be related.

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