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This is VAERS ID 1051803

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1051803
VAERS Form:2
Age:47.0
Sex:Female
Location:Georgia
Vaccinated:2021-01-08
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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- not the facility that administered the vaccine
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown- not the facility that administered the vaccine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: unknown, was informed by Health Director that person had passed away


Changed on 5/7/2021

VAERS ID: 1051803 Before After
VAERS Form:2
Age:47.0
Sex:Female
Location:Georgia
Vaccinated:2021-01-08
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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- not the facility that administered the vaccine
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown- not the facility that administered the vaccine vaccine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: unknown, was informed by Health Director that person had passed away


Changed on 5/21/2021

VAERS ID: 1051803 Before After
VAERS Form:2
Age:47.0
Sex:Female
Location:Georgia
Vaccinated:2021-01-08
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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- not the facility that administered the vaccine
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown- not the facility that administered the vaccine vaccine
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: unknown, was informed by Health Director that person had passed away

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1051803&WAYBACKHISTORY=ON


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