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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 963167 |
VAERS Form: | 1 |
Age: | 88.0 |
Sex: | Male |
Location: | Delaware |
Vaccinated: | 2021-01-02 |
Onset: | 2021-01-04 |
Submitted: | 2021-01-08 |
Entered: | 2021-01-14 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 026L20A / 2 | LA / - |
Administered by: Other Purchased by: Other
Symptoms: Cardiac arrest, Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-04
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE
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