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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 915880 |
VAERS Form: | 2 |
Age: | 99.0 |
Sex: | Male |
Location: | Montana |
Vaccinated: | 2020-12-30 |
Onset: | 2020-12-30 |
Submitted: | 0000-00-00 |
Entered: | 2020-12-31 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 037K20A / 1 | RA / IM |
Administered by: Public Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-31
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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Patient died within 12 hours of receiving the vaccine.
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