VAERS ID: |
935222 (history) |
Form: |
Version 2.0 |
Age: |
73.0 |
Sex: |
Male |
Location: |
Florida |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-07 |
Days after vaccination: | 8 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-11 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20A / 1 |
LA / IM |
Administered by: Private Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
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: Oxybutynin Chloride, Lasix 80mg, hydyralazine 50mg, amlodipine 10mg, amitriptyline 10mg, ASA, Klor-Con 20meq, Tylenol, allopurinol 100mg, Vit D3, turmeric 400mg, Lipitor 80mg, gabapentin 100mg, baclofen 5mg, candesartan 32mg, insulin lispro Current Illness: No acute illnesses Preexisting Conditions: Diabetes, CKD, CHF, HTN Allergies: NKA Diagnostic Lab Data: CDC Split Type:
Write-up: Patient was reported to be deceased at home by law enforcement on 1/7/21 |