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This is VAERS ID 1053788

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1053788
VAERS Form:2
Age:93.0
Sex:Female
Location:Tennessee
Vaccinated:2021-02-02
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Received call that patient is now deceased


Changed on 5/7/2021

VAERS ID: 1053788 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Tennessee
Vaccinated:2021-02-02
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported reported
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Received call that patient is now deceased


Changed on 5/21/2021

VAERS ID: 1053788 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Tennessee
Vaccinated:2021-02-02
Onset:2021-02-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported reported
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Received call that patient is now deceased

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