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This is VAERS ID 921175

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 921175
VAERS Form:2
Age:77.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-03
Onset:2021-01-03
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea
Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea
Allergies: NKA
Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER
CDC 'Split Type':

Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4,


Changed on 5/7/2021

VAERS ID: 921175 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-03
Onset:2021-01-03
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea
Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea
Allergies: NKA NKA
Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER
CDC 'Split Type':

Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4,


Changed on 5/14/2021

VAERS ID: 921175 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-03
Onset:2021-01-03
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-05
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea
Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea
Allergies: NKA NKA
Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER
CDC 'Split Type':

Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4,

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