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This is VAERS ID 1055563

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1055563
VAERS Form:2
Age:93.0
Sex:Female
Location:Washington
Vaccinated:2021-02-05
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Pt tested positive for COVID-19 on 2/10/2021 and died from illness related to COVID-19 on hospice at home on 2/18/2021, per care facility.


Changed on 5/7/2021

VAERS ID: 1055563 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Washington
Vaccinated:2021-02-05
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Pt tested positive for COVID-19 on 2/10/2021 and died from illness related to COVID-19 on hospice at home on 2/18/2021, per care facility.


Changed on 5/21/2021

VAERS ID: 1055563 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Washington
Vaccinated:2021-02-05
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-18
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: Pt tested positive for COVID-19 on 2/10/2021 and died from illness related to COVID-19 on hospice at home on 2/18/2021, per care facility.

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