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This is VAERS ID 405821

History of Changes from the VAERS Wayback Machine

First Appeared on 11/3/2010

VAERS ID: 405821
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / - UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 2/4/2011

VAERS ID: 405821 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / - 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 4/13/2011

VAERS ID: 405821 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiomegaly, Death, Pulmonary oedema, Left ventricular hypertrophy, Congenital cardiovascular anomaly, Bronchial hyperreactivity

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 5/13/2011

VAERS ID: 405821 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiomegaly, Death, Pulmonary oedema, Left ventricular hypertrophy, Congenital cardiovascular anomaly, Bronchial hyperreactivity

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 6/14/2014

VAERS ID: 405821 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 4/14/2017

VAERS ID: 405821 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 0 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 9/14/2017

VAERS ID: 405821 Before After
VAERS Form:(blank) 1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 0 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 2/14/2018

VAERS ID: 405821 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 6/14/2018

VAERS ID: 405821 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 8/14/2018

VAERS ID: 405821 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 9/14/2018

VAERS ID: 405821 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.


Changed on 10/14/2018

VAERS ID: 405821 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:New Jersey
Vaccinated:2010-08-30
Onset:2010-09-27
Submitted:2010-10-27
Entered:2010-10-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1333Y / 1 UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Death

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2010-09-27
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: LIPITOR
Current Illness: Cardiac disorder; Asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC 'Split Type': WAES1010USA02704

Write-up: Information has been received from a physician concerning a 15 year old male with asthma and "cardiac history" (unspecified) who on 30-AUG-2010 was vaccinated with GARDASIL (Lot number 665607/1333Y). Concomitant therapy included LIPITOR. On 27-SEP-2010 the patient died while playing hockey. The physician reported "awaiting autopsy results". At the time of report no further information was available. The reporter considered death to be life-threatening. A lot check has been initiated. Additional information has been requested.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=405821&WAYBACKHISTORY=ON


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