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This is VAERS ID 1111699

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1111699
VAERS Form:2
Age:69.0
Sex:Male
Location:Missouri
Vaccinated:2021-03-03
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest X-ray abnormal, Death, Renal failure, Respiratory failure, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown BP med
Current Illness: None
Preexisting Conditions: Intellectual disability, hypertension
Allergies: None
Diagnostic Lab Data: Positive COVID 19 test on admit CXR findings c/w COVID PNA Renal failure 2/2 COVID
CDC 'Split Type':

Write-up: Patient developed symptomatic COVID infection with symptoms starting 3/13, was admitted to the hospital for respiratory failure on 3/16 and expired on 3/18/21


Changed on 5/7/2021

VAERS ID: 1111699 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Missouri
Vaccinated:2021-03-03
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest X-ray abnormal, Death, Renal failure, Respiratory failure, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown BP med
Current Illness: None
Preexisting Conditions: Intellectual disability, hypertension
Allergies: None None
Diagnostic Lab Data: Positive COVID 19 test on admit CXR findings c/w COVID PNA Renal failure 2/2 COVID
CDC 'Split Type':

Write-up: Patient developed symptomatic COVID infection with symptoms starting 3/13, was admitted to the hospital for respiratory failure on 3/16 and expired on 3/18/21


Changed on 5/21/2021

VAERS ID: 1111699 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Missouri
Vaccinated:2021-03-03
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Chest X-ray abnormal, Death, Renal failure, Respiratory failure, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-18
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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown BP med
Current Illness: None
Preexisting Conditions: Intellectual disability, hypertension
Allergies: None None
Diagnostic Lab Data: Positive COVID 19 test on admit CXR findings c/w COVID PNA Renal failure 2/2 COVID
CDC 'Split Type':

Write-up: Patient developed symptomatic COVID infection with symptoms starting 3/13, was admitted to the hospital for respiratory failure on 3/16 and expired on 3/18/21

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