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This is VAERS ID 962940

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 962940
VAERS Form:2
Age:83.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.


Changed on 5/7/2021

VAERS ID: 962940 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine Galantamine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.


Changed on 5/14/2021

VAERS ID: 962940 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-20
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine Galantamine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.

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