National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts.org
Search Results

This is VAERS ID 1082759

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1082759
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/7/2021

VAERS ID: 1082759 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death


Changed on 5/21/2021

VAERS ID: 1082759 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-04
Onset:2021-03-07
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1082759&WAYBACKHISTORY=ON


Copyright © 2022 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166