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This is VAERS ID 1100865

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1100865
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-13
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
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: Cefuroxime, Lansoprazole, Sulfasalazine, Azulfidine, Amoxicillin, Lisinopril, Fluticasone Nasal Spray, Tenormin, Atenolol,
Current Illness: Hospitalized for Pneumonia 2-8-2021
Preexisting Conditions: Hypertension, obesity
Allergies: Unknown
Diagnostic Lab Data: Decedent is currently at facility awaiting further examination/investigation.
CDC 'Split Type':

Write-up: Patient died within 24 hours of vaccine. Unknown at this time if related.


Changed on 5/7/2021

VAERS ID: 1100865 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-13
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
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: Cefuroxime, Lansoprazole, Sulfasalazine, Azulfidine, Amoxicillin, Lisinopril, Fluticasone Nasal Spray, Tenormin, Atenolol,
Current Illness: Hospitalized for Pneumonia 2-8-2021
Preexisting Conditions: Hypertension, obesity
Allergies: Unknown Unknown
Diagnostic Lab Data: Decedent is currently at facility awaiting further examination/investigation.
CDC 'Split Type':

Write-up: Patient died within 24 hours of vaccine. Unknown at this time if related.


Changed on 5/14/2021

VAERS ID: 1100865 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Michigan
Vaccinated:2021-03-13
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
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: Cefuroxime, Lansoprazole, Sulfasalazine, Azulfidine, Amoxicillin, Lisinopril, Fluticasone Nasal Spray, Tenormin, Atenolol,
Current Illness: Hospitalized for Pneumonia 2-8-2021
Preexisting Conditions: Hypertension, obesity
Allergies: Unknown Unknown
Diagnostic Lab Data: Decedent is currently at facility awaiting further examination/investigation.
CDC 'Split Type':

Write-up: Patient died within 24 hours of vaccine. Unknown at this time if related.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1100865&WAYBACKHISTORY=ON


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