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This is VAERS ID 1080671

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1080671
VAERS Form:2
Age:74.0
Sex:Male
Location:Florida
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Chills, Confusional state, Cough, Death, Dyspnoea, Nausea, Pyrexia, Vomiting, Mental status changes, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccine 1/26/2021, complained of fever and chills post vaccine. Daughter reported worsening symptoms to confusion, decreased appetite, N/V and chest pain. Dry cough and SOB. Patient admitted to facility for Chest pain, AMS on 2/2/2021. Expired 2/2/2021.


Changed on 5/7/2021

VAERS ID: 1080671 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Florida
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Chills, Confusional state, Cough, Death, Dyspnoea, Nausea, Pyrexia, Vomiting, Mental status changes, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccine 1/26/2021, complained of fever and chills post vaccine. Daughter reported worsening symptoms to confusion, decreased appetite, N/V and chest pain. Dry cough and SOB. Patient admitted to facility for Chest pain, AMS on 2/2/2021. Expired 2/2/2021.


Changed on 5/21/2021

VAERS ID: 1080671 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Florida
Vaccinated:2021-01-26
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Chest pain, Chills, Confusional state, Cough, Death, Dyspnoea, Nausea, Pyrexia, Vomiting, Mental status changes, Decreased appetite

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-02
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: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received vaccine 1/26/2021, complained of fever and chills post vaccine. Daughter reported worsening symptoms to confusion, decreased appetite, N/V and chest pain. Dry cough and SOB. Patient admitted to facility for Chest pain, AMS on 2/2/2021. Expired 2/2/2021.

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