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This is VAERS ID 915880

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 915880
VAERS Form:2
Age:99.0
Sex:Male
Location:Montana
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-31
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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died within 12 hours of receiving the vaccine.


Changed on 5/7/2021

VAERS ID: 915880 Before After
VAERS Form:2
Age:99.0
Sex:Male
Location:Montana
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-31
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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies. allergies.
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died within 12 hours of receiving the vaccine.


Changed on 5/14/2021

VAERS ID: 915880 Before After
VAERS Form:2
Age:99.0
Sex:Male
Location:Montana
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-31
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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies. allergies.
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient died within 12 hours of receiving the vaccine.

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