VAERS ID: |
914895 (history) |
Form: |
Version 2.0 |
Age: |
78.0 |
Sex: |
Male |
Location: |
Nebraska |
Vaccinated: | 2020-12-28 |
Onset: | 2020-12-30 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-30 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-30
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: Senna Plus, Loperamide, Ondansetron, Acetaminophen, Mucus & Chest Relief cough syrup, Oystershell Calcium Plus D, Vitamin D3, Escitalopram, Bupropion, Hydrocodone/Acetaminophen, Bisacodyl Suppositories Current Illness: Alzheimer''s Disease, Encephalopathy, Hypertension,Acute Kidney failure, Urine Retention, Recent UTI Preexisting Conditions: Alzheimer''s Disease, Encephalopathy, Hypertension Allergies: No known drug allergies Diagnostic Lab Data: CDC Split Type:
Write-up: Injection given on 12/28/20 - no adverse events and no issues yesterday; Death today, 12/30/20, approx.. 2am today (unknown if related - Administrator marked as natural causes) |