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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 933578 |
VAERS Form: | 2 |
Age: | 43.0 |
Sex: | Male |
Location: | New York |
Vaccinated: | 2021-01-08 |
Onset: | 0000-00-00 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-11 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 012L20A / 1 | LA / IM |
Administered by: Public Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:0000-00-00
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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021
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