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This is VAERS ID 1106737

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1106737
VAERS Form:2
Age:82.0
Sex:Male
Location:Washington
Vaccinated:2021-03-11
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Death, Malaise

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: melatonin, calcium, vitamin D, famotidine, quetiapine 50 mg QHS
Current Illness: Normal pressure hydrocephalus -- s/p VP shunt with dementia
Preexisting Conditions: BPH, C-spine fracture with myelopathy, GERD
Allergies: opiates, pencillins (hives)
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: weakness/malaise per daughter, death on 3/14 (did have underlying medical conditions)


Changed on 5/7/2021

VAERS ID: 1106737 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Washington
Vaccinated:2021-03-11
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Death, Malaise

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: melatonin, calcium, vitamin D, famotidine, quetiapine 50 mg QHS
Current Illness: Normal pressure hydrocephalus -- s/p VP shunt with dementia
Preexisting Conditions: BPH, C-spine fracture with myelopathy, GERD
Allergies: opiates, pencillins (hives) (hives)
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: weakness/malaise per daughter, death on 3/14 (did have underlying medical conditions)


Changed on 5/14/2021

VAERS ID: 1106737 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Washington
Vaccinated:2021-03-11
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Death, Malaise

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: melatonin, calcium, vitamin D, famotidine, quetiapine 50 mg QHS
Current Illness: Normal pressure hydrocephalus -- s/p VP shunt with dementia
Preexisting Conditions: BPH, C-spine fracture with myelopathy, GERD
Allergies: opiates, pencillins (hives) (hives)
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: weakness/malaise per daughter, death on 3/14 (did have underlying medical conditions)

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