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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1120979

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Case Details

VAERS ID: 1120979 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-19
Onset:2021-03-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Foaming at mouth
SMQs:, Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Generalised convulsive seizures following immunisation (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: APIXABAN 5MG 1 BID APILSOL SOLUTION 5unti/0.1ml TB TEST CARVEDILOL 3.125MG 1 QD ERGOCALCIFEROL 1.25MG 1 EVERY WED EZETIMIBE 10MG 1 QD FERROUS SULFATE 325MG 1 QD FOLIC ACID 1MG 1 QD GABAPENTIN 300MG 1 TID LEVOTHYROXINE 25MCG 1 QD OXYCODONE 5
Current Illness: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA ANEMIA ACQUIRED COAGULATION FACTOR DEFICIENCY THROMBOCYTOPENIA HYPOTHROIDISM SLEEP APNEA POLYNEUROPATHY ESSENTIAL PRIMARY HYPERTENSION HEMIPLEGIA AD HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON DOMINANT SIDE ESOPHAGITIS GERD CIRRHOSIS OF LIVER NONALCOHOLIC STEATOHEPATITIS ASCITES URINARY DEVICE DEPENDENCE ON SUPPLEMENTAL OXYGEN HISTORYOF FALLING
Preexisting Conditions: SEE ABOVE
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: NO IMMEDIATE LOCAL REACTION, NO REACTION 30MINUTES LATER. FOUND FOAMING AT THE MOUTH NEXT MORNING. PRONOUNCED DEAD AT HOSPITAL.


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