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This is VAERS ID 1006216

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1006216
VAERS Form:2
Age:100.0
Sex:Female
Location:South Carolina
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Medications the resident was currently recieving: AmLODIPine Besylate Tablet 5 MG Losartan Potassium Tablet 50 MG Melatonin Tablet 5 MG Povidone-Iodine Solution 10 % Remeron Tablet 15 MG (Mirtazapine) Tamsulosin HCl Capsule 0.4 MG Lactobaci
Current Illness: None
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY PAROXYSMAL ATRIAL FIBRILLATION HYPOXEMIA BRADYCARDIA, UNSPECIFIED PRESENCE OF UROGENITAL IMPLANTS
Allergies: No known allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Notes of the checks/events with resident: 18:36 2/2/21 Resident had no complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 97.2 02:50 2/3/2021 Resident received 2nd COVID vaccine. No complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 98.1 07:15 2/3/2021 Resident was observed not breathing. 911 was contacted along with the doctor. Resident was confirmed having passed away.


Changed on 5/7/2021

VAERS ID: 1006216 Before After
VAERS Form:2
Age:100.0
Sex:Female
Location:South Carolina
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Medications the resident was currently recieving: AmLODIPine Besylate Tablet 5 MG Losartan Potassium Tablet 50 MG Melatonin Tablet 5 MG Povidone-Iodine Solution 10 % Remeron Tablet 15 MG (Mirtazapine) Tamsulosin HCl Capsule 0.4 MG Lactobaci
Current Illness: None
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY PAROXYSMAL ATRIAL FIBRILLATION HYPOXEMIA BRADYCARDIA, UNSPECIFIED PRESENCE OF UROGENITAL IMPLANTS
Allergies: No known allergies allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Notes of the checks/events with resident: 18:36 2/2/21 Resident had no complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 97.2 02:50 2/3/2021 Resident received 2nd COVID vaccine. No complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 98.1 07:15 2/3/2021 Resident was observed not breathing. 911 was contacted along with the doctor. Resident was confirmed having passed away.


Changed on 5/14/2021

VAERS ID: 1006216 Before After
VAERS Form:2
Age:100.0
Sex:Female
Location:South Carolina
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Medications the resident was currently recieving: AmLODIPine Besylate Tablet 5 MG Losartan Potassium Tablet 50 MG Melatonin Tablet 5 MG Povidone-Iodine Solution 10 % Remeron Tablet 15 MG (Mirtazapine) Tamsulosin HCl Capsule 0.4 MG Lactobaci
Current Illness: None
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY PAROXYSMAL ATRIAL FIBRILLATION HYPOXEMIA BRADYCARDIA, UNSPECIFIED PRESENCE OF UROGENITAL IMPLANTS
Allergies: No known allergies allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Notes of the checks/events with resident: 18:36 2/2/21 Resident had no complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 97.2 02:50 2/3/2021 Resident received 2nd COVID vaccine. No complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 98.1 07:15 2/3/2021 Resident was observed not breathing. 911 was contacted along with the doctor. Resident was confirmed having passed away.

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