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This is VAERS ID 1055791

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1055791
VAERS Form:2
Age:82.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-11
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge


Changed on 5/7/2021

VAERS ID: 1055791 Before After
VAERS Form:2
Age:82.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-11
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes Yes
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge


Changed on 5/21/2021

VAERS ID: 1055791 Before After
VAERS Form:2
Age:82.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-11
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Illness

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes Yes
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge

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