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This is VAERS ID 1088180

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1088180
VAERS Form:2
Age:93.0
Sex:Male
Location:Arkansas
Vaccinated:2021-03-05
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: See Below
Preexisting Conditions: On Hospice due to: Chronic systolic (congestive) heart failure, Chronic kidney disease stage 3, Sick sinus syndrome, Unspecified atrial fibrillation, Presence of cardiac pacemaker, Muscle weakness, Alzheimer''s Disease
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospice on 8/11/20. He experienced normal progression of his diseases until his death on 3/9/21.


Changed on 5/7/2021

VAERS ID: 1088180 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:Arkansas
Vaccinated:2021-03-05
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: See Below
Preexisting Conditions: On Hospice due to: Chronic systolic (congestive) heart failure, Chronic kidney disease stage 3, Sick sinus syndrome, Unspecified atrial fibrillation, Presence of cardiac pacemaker, Muscle weakness, Alzheimer''s Disease
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospice on 8/11/20. He experienced normal progression of his diseases until his death on 3/9/21.


Changed on 5/21/2021

VAERS ID: 1088180 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:Arkansas
Vaccinated:2021-03-05
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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: See Below
Preexisting Conditions: On Hospice due to: Chronic systolic (congestive) heart failure, Chronic kidney disease stage 3, Sick sinus syndrome, Unspecified atrial fibrillation, Presence of cardiac pacemaker, Muscle weakness, Alzheimer''s Disease
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospice on 8/11/20. He experienced normal progression of his diseases until his death on 3/9/21.

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