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This is VAERS ID 1093939

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1093939
VAERS Form:2
Age:83.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Blood Thinner
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No report of negative event after 15 min wait past receipt of vaccine. Notified by Coronor, on 3/11/2021 that this patient expired on 3/11/2021 at home. Not sent to hospital. Pronounced at home. Sent to Funeral Home


Changed on 5/7/2021

VAERS ID: 1093939 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Blood Thinner
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown Unknown
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No report of negative event after 15 min wait past receipt of vaccine. Notified by Coronor, on 3/11/2021 that this patient expired on 3/11/2021 at home. Not sent to hospital. Pronounced at home. Sent to Funeral Home


Changed on 5/14/2021

VAERS ID: 1093939 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Mississippi
Vaccinated:2021-03-05
Onset:2021-03-11
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-11
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: Blood Thinner
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown Unknown
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No report of negative event after 15 min wait past receipt of vaccine. Notified by Coronor, on 3/11/2021 that this patient expired on 3/11/2021 at home. Not sent to hospital. Pronounced at home. Sent to Funeral Home

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1093939&WAYBACKHISTORY=ON


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