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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 935222 |
VAERS Form: | 2 |
Age: | 73.0 |
Sex: | Male |
Location: | Florida |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-07 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-11 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 025J20A / 1 | LA / IM |
Administered by: Private Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-07
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: 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
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