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This is VAERS ID 914690

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

VAERS ID: 914690
VAERS Form:2
Age:83.0
Sex:Female
Location:California
Vaccinated:2020-12-23
Onset:2020-12-24
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-26
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: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC 'Split Type':

Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020.


Changed on 5/7/2021

VAERS ID: 914690 Before After
VAERS Form:2
Age:83.0
Sex:Female
Location:California
Vaccinated:2020-12-23
Onset:2020-12-24
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-26
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: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC 'Split Type':

Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020.


Changed on 5/14/2021

VAERS ID: 914690 Before After
VAERS Form:2
Age:83.0
Sex:Female
Location:California
Vaccinated:2020-12-23
Onset:2020-12-24
Submitted:0000-00-00
Entered:2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living      Purchased by: ??
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-26
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: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC 'Split Type':

Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=914690&WAYBACKHISTORY=ON


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