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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 930876 |
VAERS Form: | 2 |
Age: | 88.0 |
Sex: | Male |
Location: | Texas |
Vaccinated: | 2021-01-07 |
Onset: | 2021-01-08 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-08 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 027L20A / 1 | RA / IM |
Administered by: Pharmacy Purchased by: ??
Symptoms: Death, X-ray with contrast
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-08
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:
Current Illness:
Preexisting Conditions: Prostate Cancer
Allergies:
Diagnostic Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.
CDC 'Split Type':
Write-up: Death
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