VAERS ID: |
920815 (history) |
Form: |
Version 2.0 |
Age: |
58.0 |
Sex: |
Female |
Location: |
Kentucky |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-04 |
Days after vaccination: | 5 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / IM |
Administered by: Private Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
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: unknown Current Illness: unknown Preexisting Conditions: Per employee health records HTN, DM, Breast CA 2016 with radiation, obesity, gastric sleeve 10 years ago, arthritis, plantar fasciitis, ankle tendonitis, DeQuarvains, carpal tunnel, anxiety Allergies: Lisinpril, Codeine, Latex , environmental (hay fever) Diagnostic Lab Data: CDC Split Type:
Write-up: Found deceased in her home, unknown cause, 6 days after vaccine. |