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This is VAERS ID 1078352

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1078352
VAERS Form:2
Age:18.0
Sex:Male
Location:Illinois
Vaccinated:2021-03-02
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Death, Fatigue, Headache, Pain, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Medical examiner report is pending.
CDC 'Split Type':

Write-up: Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home.


Changed on 5/7/2021

VAERS ID: 1078352 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Illinois
Vaccinated:2021-03-02
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Death, Fatigue, Headache, Pain, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Medical examiner report is pending.
CDC 'Split Type':

Write-up: Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home.


Changed on 5/21/2021

VAERS ID: 1078352 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Illinois
Vaccinated:2021-03-02
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Death, Fatigue, Headache, Pain, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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: Medical examiner report is pending.
CDC 'Split Type':

Write-up: Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home.

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