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VAERS ID: | 947129 |
VAERS Form: | 2 |
Age: | 101.0 |
Sex: | Female |
Location: | Georgia |
Vaccinated: | 2020-12-23 |
Onset: | 2020-12-25 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-15 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 026L20A / 1 | AR / IM |
Administered by: Private Purchased by: ??
Symptoms: Cerebrovascular accident, Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-01
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec
Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Preexisting Conditions: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Allergies: None known
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Resident received Moderna vaccine on 12/23/2020 around 5 pm. At approximately 3:35 am on 12/25/2020, resident had a CVA and died on 1/1/2021 at 3:00 am.
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