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This is VAERS ID 1103106

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1103106
VAERS Form:2
Age:80.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-15
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     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.


Changed on 5/7/2021

VAERS ID: 1103106 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-15
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNK
Current Illness: NA
Preexisting Conditions: NA
Allergies: NA 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.


Changed on 5/14/2021

VAERS ID: 1103106 Before After
VAERS Form:2
Age:80.0
Sex:Male
Location:Mississippi
Vaccinated:2021-01-15
Onset:2021-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNK
Current Illness: NA
Preexisting Conditions: NA
Allergies: NA 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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