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This is VAERS ID 1035872

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1035872
VAERS Form:2
Age:83.0
Sex:Male
Location:Texas
Vaccinated:2021-02-11
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at 8 am on 2/12; patient was deceased


Changed on 5/7/2021

VAERS ID: 1035872 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Texas
Vaccinated:2021-02-11
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at 8 am on 2/12; patient was deceased


Changed on 5/21/2021

VAERS ID: 1035872 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Texas
Vaccinated:2021-02-11
Onset:2021-02-12
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at 8 am on 2/12; patient was deceased

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