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This is VAERS ID 1036440

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036440
VAERS Form:2
Age:65.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-15
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bladder cancer stage IV, Condition aggravated, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: unknown names of medication, chemo medications, HBP, CHF medications
Current Illness: Stage 4 bladder cancer
Preexisting Conditions: Stage 4 bladder cancer, CHF
Allergies: None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died at home in hospice care from complications of stage 4 bladder cancer


Changed on 5/7/2021

VAERS ID: 1036440 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-15
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bladder cancer stage IV, Condition aggravated, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: unknown names of medication, chemo medications, HBP, CHF medications
Current Illness: Stage 4 bladder cancer
Preexisting Conditions: Stage 4 bladder cancer, CHF
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died at home in hospice care from complications of stage 4 bladder cancer


Changed on 5/21/2021

VAERS ID: 1036440 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Georgia
Vaccinated:2021-01-15
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bladder cancer stage IV, Condition aggravated, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-27
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: unknown names of medication, chemo medications, HBP, CHF medications
Current Illness: Stage 4 bladder cancer
Preexisting Conditions: Stage 4 bladder cancer, CHF
Allergies: None None
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient died at home in hospice care from complications of stage 4 bladder cancer

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