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From the 11/19/2021 release of VAERS data:

This is VAERS ID 963016

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Case Details

VAERS ID: 963016 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: denied ill symtpoms at time of vaccination
Preexisting Conditions: denied
Allergies: unknown. Denied allergies on vaccine form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown. Event occurred after leaving vaccination site


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=963016


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