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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 926600 |
VAERS Form: | 2 |
Age: | 65.0 |
Sex: | Male |
Location: | Missouri |
Vaccinated: | 2021-01-04 |
Onset: | 2021-01-06 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-07 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 37K20A / 1 | RA / IM |
Administered by: Pharmacy Purchased by: ??
Symptoms: Death, Malaise
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-06
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: Diabetes, renal insufficiency
Preexisting Conditions: Diabetes, renal insufficiency
Allergies: Penicillin, ibuprofen
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Patient did not report any signs or symptoms of adverse reaction to vaccine. Patient suffered from several comorbidities (diabetes and renal insufficiency). Patient reported not feeling well 01/06/2021 and passed away that day.
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