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This is VAERS ID 918487

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 918487
VAERS Form:2
Age:94.0
Sex:Male
Location:Michigan
Vaccinated:2020-01-02
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.


Changed on 5/7/2021

VAERS ID: 918487 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Michigan
Vaccinated:2020-01-02
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers Blockers
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.


Changed on 5/14/2021

VAERS ID: 918487 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Michigan
Vaccinated:2020-01-02
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers Blockers
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.

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