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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1103106

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Case Details

VAERS ID: 1103106 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-01-15
Onset:2021-01-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNK
Current Illness: NA
Preexisting Conditions: NA
Allergies: NA
Diagnostic Lab Data: UNK
CDC Split Type:

Write-up: Patient died on 01/24/2021. Began exhibiting symptoms similar to Covid 1 day after vaccination.


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