National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 5/14/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1077079

Case Details

VAERS ID: 1077079 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Tylenol, Sennakot, Amlodipine
Current Illness: Coccyx wound (hospice care)
Preexisting Conditions: Diabetes Type 2
Allergies: Iodine (Skin Reaction)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was alert and oriented with no signs or symptoms of sickness prior to immunization for 2nd dose of Pfizer COVID19 vaccine. Temperature 98.7. Patient under hospice care and DNR status for wound care (coccyx). Patient has no recollection of first dose, but no adverse reactions to first dose per her caregivers. Patient did not appear to have any adverse reactions to the vaccine after the 15 minute observation period. About 1 hr after vaccine administration, patient was reported deceased. No signs of swelling or allergic reaction at site of injection.

New Search

Link To This Search Result:

Government Disclaimer on use of this data

Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166