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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 937569 |
VAERS Form: | 2 |
Age: | 62.0 |
Sex: | Male |
Location: | Rhode Island |
Vaccinated: | 2021-01-02 |
Onset: | 2021-01-07 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-12 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | - / 1 | - / IM |
Administered by: Other 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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: patient reported expired 1/7/2021
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