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This is VAERS ID 958935

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 958935
VAERS Form:2
Age:92.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-19
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Aspirin, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax
Current Illness:
Preexisting Conditions: Dementia, HTN, Hypothyroidism
Allergies: Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death within 24 hours of vaccine


Changed on 5/7/2021

VAERS ID: 958935 Before After
VAERS Form:2
Age:92.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-19
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Aspirin, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax
Current Illness:
Preexisting Conditions: Dementia, HTN, Hypothyroidism
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death within 24 hours of vaccine


Changed on 5/14/2021

VAERS ID: 958935 Before After
VAERS Form:2
Age:92.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-19
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Aspirin, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax
Current Illness:
Preexisting Conditions: Dementia, HTN, Hypothyroidism
Allergies: Penicillin Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Sudden Death within 24 hours of vaccine

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