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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 1220264

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Case Details

VAERS ID: 1220264 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-03-17
Onset:2021-04-06
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Dementia
Allergies: Unkown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient was scheduled for second dose on 4/14/21. Wife called that morning to say that patient passed away on 4/6/21. Wife Callie stated he saw the neurologist on 4/1/21. On 4/6 he was doing very well in the am and pm. She put him to bed, he woke up and called to her, gasped and passed away. She reports he tolerated the 3/17 vaccination well. I called the doctor on 4/16/21 for more information but he has not returned my call as of yet.


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