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This is VAERS ID 1050281

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1050281
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Malaise, X-ray abnormal, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC 'Split Type':

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.


Changed on 5/7/2021

VAERS ID: 1050281 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Malaise, X-ray abnormal, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC 'Split Type':

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.


Changed on 5/21/2021

VAERS ID: 1050281 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:California
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Malaise, X-ray abnormal, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC 'Split Type':

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.

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