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This is VAERS ID 1039028

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1039028
VAERS Form:2
Age:59.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Systemic: no issues during observation period-Severe, Additional Details: patient received moderna immunization during the morning of 2/17/2021. patient was found by facility staff at 2:38pm with no pulse CPR was started, aed was used and ems was called. time of death 3:15pm


Changed on 5/7/2021

VAERS ID: 1039028 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Systemic: no issues during observation period-Severe, Additional Details: patient received moderna immunization during the morning of 2/17/2021. patient was found by facility staff at 2:38pm with no pulse CPR was started, aed was used and ems was called. time of death 3:15pm


Changed on 5/21/2021

VAERS ID: 1039028 Before After
VAERS Form:2
Age:59.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Systemic: no issues during observation period-Severe, Additional Details: patient received moderna immunization during the morning of 2/17/2021. patient was found by facility staff at 2:38pm with no pulse CPR was started, aed was used and ems was called. time of death 3:15pm

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