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This is VAERS ID 926568

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 926568
VAERS Form:2
Age:77.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-28
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Absence of immediate treatment response

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020


Changed on 5/7/2021

VAERS ID: 926568 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-28
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Absence of immediate treatment response

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin vicodin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020


Changed on 5/14/2021

VAERS ID: 926568 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-28
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Absence of immediate treatment response

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin vicodin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020

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