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This is VAERS ID 956962

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 956962
VAERS Form:2
Age:74.0
Sex:Male
Location:New York
Vaccinated:2021-01-06
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER COVID 19 KNOWN< / 1 UN / UN

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hyperhidrosis, Hypotension, Hypoxia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unavail
Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020
Preexisting Conditions: as above PAtient had accute respiratory distress followed prolptly by cardiac arrest
Allergies: NKDA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020


Changed on 5/7/2021

VAERS ID: 956962 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:New York
Vaccinated:2021-01-06
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER COVID 19 KNOWN< / 1 UN / UN

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hyperhidrosis, Hypotension, Hypoxia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unavail
Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020
Preexisting Conditions: as above PAtient had accute respiratory distress followed prolptly by cardiac arrest
Allergies: NKDA NKDA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020


Changed on 5/14/2021

VAERS ID: 956962 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:New York
Vaccinated:2021-01-06
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER COVID 19 KNOWN< / 1 UN / UN

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Hyperhidrosis, Hypotension, Hypoxia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-19
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: Unavail
Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020
Preexisting Conditions: as above PAtient had accute respiratory distress followed prolptly by cardiac arrest
Allergies: NKDA NKDA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=956962&WAYBACKHISTORY=ON


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