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From the 12/31/2003 release of VAERS data (an older release, current is 4/30/2021):

This is VAERS ID 91791



Case Details

VAERS ID: 91791 (history)  
Form: Version .0  
Age: 79.1  
Sex: Female  
Location: Unknown  
Vaccinated:1996-10-15
Onset:1996-10-17
   Days after vaccination:2
Submitted: 1996-10-22
   Days after onset:5
Entered: 1996-11-11
   Days after submission:20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUSHIELD 1996-1997 / WYETH - / - - / IM

Administered by: Private       Purchased by: Unknown
Symptoms: DIARRHEA, NAUSEA, PAIN ABDO, SYNCOPE
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-10-17
   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: Cardizem, Cyodur,asthma shot, pred
Current Illness: unk
Preexisting Conditions: asthma, heart problems, arthritis, aortic aneurysm
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax 15OCT96 & 6PM on 17OCT96 pt fainted;upon arousal pt c.o stomach pain, diarrhea, & nausea;pt dies in home 8:45Pm;


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20031231&IDNUMBER=91791


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