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National Vaccine Information Center Your Health. Your Family. Your Choice. |
MedAlerts.org |
| History of Changes from the VAERS Wayback Machine |
| VAERS ID: | 918388 |
| VAERS Form: | 2 |
| Age: | 65.0 |
| Sex: | Female |
| Location: | Florida |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Submitted: | 0000-00-00 |
| Entered: | 2021-01-04 |
| Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EL0140 / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-01
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: Albuteral Sulfate Amlodipine Carvedilol Ipratropium Levetiracetam Olanzapine Sodium Chloride Symbicort Valproic Acid
Current Illness: No acute illness at time of vaccination. History of: CVA SCPT Dementia Seizure Disorder HTN COPD
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type': NHSNfacilitynumber48433
Write-up: Resident found unresponsive without pulse, respirations at 04:30 CPR performed, expired at 04:52 by Rescue
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Submitted: | 0000-00-00 |
| Entered: | 2021-01-04 |
| Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EL0140 / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-01
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: Albuteral Sulfate Amlodipine Carvedilol Ipratropium Levetiracetam Olanzapine Sodium Chloride Symbicort Valproic Acid
Current Illness: No acute illness at time of vaccination. History of: CVA SCPT Dementia Seizure Disorder HTN COPD
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type': NHSNfacilitynumber48433 (blank)
Write-up: Resident found unresponsive without pulse, respirations at 04:30 CPR performed, expired at 04:52 by Rescue
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