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This is VAERS ID 950073

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 950073
VAERS Form:2
Age:63.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death, Headache, Lethargy, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal, Mycobacterium tuberculosis complex test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC 'Split Type':

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.


Changed on 5/7/2021

VAERS ID: 950073 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death, Headache, Lethargy, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal, Mycobacterium tuberculosis complex test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC 'Split Type':

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.


Changed on 5/14/2021

VAERS ID: 950073 Before After
VAERS Form:2
Age:63.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Body temperature increased, Death, Headache, Lethargy, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal, Mycobacterium tuberculosis complex test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC 'Split Type':

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.

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