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This is VAERS ID 1125903

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1125903
VAERS Form:2
Age:86.0
Sex:Female
Location:Maine
Vaccinated:2021-03-18
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-23
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: Amitriptyline, artificial tears, aspirin, atenolol, citalopram, clonazepam, glipizide, melatonin, Montelukast, multivitamin, omeprazole, refresh plus eye drops.
Current Illness: Thrombocytopenia (only on one lab, platelet count 122 on 2/26/21- repeat lab 3/18/21 revealed platelet count of 155)
Preexisting Conditions: Chronic PTSD, hair loss, hyperlipidemia, controlled type two diabetes, dysthymic disorder, complicated grief
Allergies: Acetaminophen, codeine, oxycodone, sulfa, morphine (none listed as anaphylactic type reactions)
Diagnostic Lab Data: Recent labs performed include CBC on 3/18/21 but this was not related to the COVID 19 vaccination.
CDC 'Split Type':

Write-up: Patient stayed in health center under routine observation for 15-20 minutes after vaccine injection and showed no symptoms and was subsequently released to go home. A friend drove her home after her injection. On 3/19/21 at 09:09 a.m. a medical assistant from our facility called pt. to inform her of normal lab results. On 3/21/21 at approximately 05:43 p.m. the on call provider took a call from Deputy from the Sherriffs office informing us that pt. was found deceased in her bed on the afternoon of 3/21/21.


Changed on 5/7/2021

VAERS ID: 1125903 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:Maine
Vaccinated:2021-03-18
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-23
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: Amitriptyline, artificial tears, aspirin, atenolol, citalopram, clonazepam, glipizide, melatonin, Montelukast, multivitamin, omeprazole, refresh plus eye drops.
Current Illness: Thrombocytopenia (only on one lab, platelet count 122 on 2/26/21- repeat lab 3/18/21 revealed platelet count of 155)
Preexisting Conditions: Chronic PTSD, hair loss, hyperlipidemia, controlled type two diabetes, dysthymic disorder, complicated grief
Allergies: Acetaminophen, codeine, oxycodone, sulfa, morphine (none listed as anaphylactic type reactions) reactions)
Diagnostic Lab Data: Recent labs performed include CBC on 3/18/21 but this was not related to the COVID 19 vaccination.
CDC 'Split Type':

Write-up: Patient stayed in health center under routine observation for 15-20 minutes after vaccine injection and showed no symptoms and was subsequently released to go home. A friend drove her home after her injection. On 3/19/21 at 09:09 a.m. a medical assistant from our facility called pt. to inform her of normal lab results. On 3/21/21 at approximately 05:43 p.m. the on call provider took a call from Deputy from the Sherriffs office informing us that pt. was found deceased in her bed on the afternoon of 3/21/21.


Changed on 5/21/2021

VAERS ID: 1125903 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:Maine
Vaccinated:2021-03-18
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-23
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: Amitriptyline, artificial tears, aspirin, atenolol, citalopram, clonazepam, glipizide, melatonin, Montelukast, multivitamin, omeprazole, refresh plus eye drops.
Current Illness: Thrombocytopenia (only on one lab, platelet count 122 on 2/26/21- repeat lab 3/18/21 revealed platelet count of 155)
Preexisting Conditions: Chronic PTSD, hair loss, hyperlipidemia, controlled type two diabetes, dysthymic disorder, complicated grief
Allergies: Acetaminophen, codeine, oxycodone, sulfa, morphine (none listed as anaphylactic type reactions) reactions)
Diagnostic Lab Data: Recent labs performed include CBC on 3/18/21 but this was not related to the COVID 19 vaccination.
CDC 'Split Type':

Write-up: Patient stayed in health center under routine observation for 15-20 minutes after vaccine injection and showed no symptoms and was subsequently released to go home. A friend drove her home after her injection. On 3/19/21 at 09:09 a.m. a medical assistant from our facility called pt. to inform her of normal lab results. On 3/21/21 at approximately 05:43 p.m. the on call provider took a call from Deputy from the Sherriffs office informing us that pt. was found deceased in her bed on the afternoon of 3/21/21.

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