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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 964636 |
VAERS Form: | 2 |
Age: | 81.0 |
Sex: | Male |
Location: | Unknown |
Vaccinated: | 2020-12-17 |
Onset: | 2020-12-22 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-09 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EK5730 / 1 | RA / IM |
Administered by: Other Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-22
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Pt on hospice in facility for severe cardiomyopathy unable to perform interventions received vaccine without adverse sequelae died 5 days later. Reporting as required. Narrative: Reporting as required patient death 5 days after immunization with Pfizer vaccine. However, no adverse sequelae were noted to the vaccine in the 15minute observation period, nor in the days following the immunization related to the vaccine. The patient denied any prior severe reaction to this vaccine or its components, and the patient gave verbal consent to receive the vaccine. Patient had been in the facility on hospice since 11/18/20 for severe decompensated HF and newly diagnosed cardiomyopathy, unable to perform interventions, also LE ischemic wounds with very poor potential to heal due to advanced PVD.
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