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This is VAERS ID 930910

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 930910
VAERS Form:2
Age:52.0
Sex:Female
Location:Hawaii
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.


Changed on 5/7/2021

VAERS ID: 930910 Before After
VAERS Form:2
Age:52.0
Sex:Female
Location:Hawaii
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex latex
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.


Changed on 5/14/2021

VAERS ID: 930910 Before After
VAERS Form:2
Age:52.0
Sex:Female
Location:Hawaii
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex latex
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.

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