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This is VAERS ID 937569

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 937569
VAERS Form:2
Age:62.0
Sex:Male
Location:Rhode Island
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-07
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient reported expired 1/7/2021


Changed on 5/7/2021

VAERS ID: 937569 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Rhode Island
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-07
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient reported expired 1/7/2021


Changed on 5/14/2021

VAERS ID: 937569 Before After
VAERS Form:2
Age:62.0
Sex:Male
Location:Rhode Island
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-07
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: patient reported expired 1/7/2021

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=937569&WAYBACKHISTORY=ON


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