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This is VAERS ID 958565

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 958565
VAERS Form:2
Age:71.0
Sex:Male
Location:Florida
Vaccinated:2021-01-11
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Arrhythmia, Chest discomfort, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week
Current Illness: lung infection treated with antibiotics a couple of weeks ago
Preexisting Conditions: Hypertension, COPD
Allergies: None Known
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia.


Changed on 5/7/2021

VAERS ID: 958565 Before After
VAERS Form:2
Age:71.0
Sex:Male
Location:Florida
Vaccinated:2021-01-11
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Arrhythmia, Chest discomfort, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week
Current Illness: lung infection treated with antibiotics a couple of weeks ago
Preexisting Conditions: Hypertension, COPD
Allergies: None Known Known
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia.


Changed on 5/14/2021

VAERS ID: 958565 Before After
VAERS Form:2
Age:71.0
Sex:Male
Location:Florida
Vaccinated:2021-01-11
Onset:2021-01-11
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Arrhythmia, Chest discomfort, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week
Current Illness: lung infection treated with antibiotics a couple of weeks ago
Preexisting Conditions: Hypertension, COPD
Allergies: None Known Known
Diagnostic Lab Data: Unknown
CDC 'Split Type':

Write-up: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia.

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