National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1085019

Government Disclaimer on use of this data



Case Details

VAERS ID: 1085019 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Washington  
Vaccinated:2020-03-03
Onset:2021-03-05
   Days after vaccination:367
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Death
SMQs:, Retroperitoneal fibrosis (broad)

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: Multi vitamin, promethazine 25 mg, omeprazole 20 mg, cyclobenzaprine, 10 mg, oxycodone/APAP 5/325mg, gabapentin 800 mg, simvastatin 20 mg tab, metformin 1000 mg tab, nortriptyline 50 mg cap, zolpidem 10 mg tab, Ketorolac 60 mg injection 2 t
Current Illness: Chronic pain, HTN, DM, Cervicalgia, nausea, insomnia
Preexisting Conditions: Tobacco abuse, HTN, Diabetes mellitus, DJD, Cervicalgia, osteoarthritis, chronic pain, opioid use, diabetic polyneuropathy, carpal tunnel syndrome bilaterally, atopic dermatitis, bursitis , history of DVT, LE edema, chronic nausea, hyperlipidemia, insomnia,
Allergies: Benzodiazepines, celecoxib, codeine, diphenhydramine HCL, inositol Niacinate, Metaxalone, Niacinamide, oxycodone HCL, ASA, horse/equine containing products,, erythromycin base products, shellfish derived, bee venom
Diagnostic Lab Data: Unknown if autopsy will be performed.
CDC Split Type:

Write-up: Had vaccine on 3/3/2021 at approximately 1 PM. She was found on her couch deceased on 3/8/2021. Possible death on 3/5/2021. She called her sister and told sister that back hurt worse than usual and she would lay on the couch and rest. This is where she was found. Unknown if from vaccine, but due to vaccination on Wednesday proceeding her death, report is being filed.


New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1085019


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