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This is VAERS ID 959001

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 959001
VAERS Form:2
Age:55.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-15
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Nausea, Pulse absent, Resuscitation, Unresponsive to stimuli

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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.


Changed on 5/7/2021

VAERS ID: 959001 Before After
VAERS Form:2
Age:55.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-15
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Nausea, Pulse absent, Resuscitation, Unresponsive to stimuli

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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry Strawberry
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.


Changed on 5/14/2021

VAERS ID: 959001 Before After
VAERS Form:2
Age:55.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-15
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Nausea, Pulse absent, Resuscitation, Unresponsive to stimuli

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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry Strawberry
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.

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