National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts.org
Search Results

This is VAERS ID 1110099

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1110099
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-03-10
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 3/12/21 Sudden cardiac arrest at home; unable to be resuscitated at scene (Brother) Caller is a family friend who was asked by family to call and report incident. If f/u is needed, please contact him first. Current Medical History: unknown by caller Current Medications: unknown by caller


Changed on 5/7/2021

VAERS ID: 1110099 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-03-10
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 3/12/21 Sudden cardiac arrest at home; unable to be resuscitated at scene (Brother) Caller is a family friend who was asked by family to call and report incident. If f/u is needed, please contact him first. Current Medical History: unknown by caller Current Medications: unknown by caller


Changed on 5/21/2021

VAERS ID: 1110099 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-03-10
Onset:2021-03-12
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-12
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 3/12/21 Sudden cardiac arrest at home; unable to be resuscitated at scene (Brother) Caller is a family friend who was asked by family to call and report incident. If f/u is needed, please contact him first. Current Medical History: unknown by caller Current Medications: unknown by caller

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1110099&WAYBACKHISTORY=ON


Copyright © 2022 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166