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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 923993 |
VAERS Form: | 2 |
Age: | 62.0 |
Sex: | Male |
Location: | North Carolina |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-02 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-06 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 039K20A / 1 | AR / IM |
Administered by: Private Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-02
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: Unknown
Current Illness: No
Preexisting Conditions: History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma
Allergies: Hay fever
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Patient was vaccinated Dec 30, 2020. Prime dose of Moderna vaccine. Observed for full 15 minutes post-injection. No complaints when asked during observation. Released. Subsequently, vaccine clinic staff learned from the patient''s supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021. By report from the supervisor, the patient was found dead at his home. The patient''s primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021). Electronic Medical Record without any information since the vaccination.
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