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This is VAERS ID 963016

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 963016
VAERS Form:2
Age:65.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-01-14
Onset:2021-01-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: 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


Changed on 5/7/2021

VAERS ID: 963016 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-01-14
Onset:2021-01-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: unknown
Current Illness: denied ill symtpoms at time of vaccination
Preexisting Conditions: denied
Allergies: unknown. Denied allergies on vaccine form form
Diagnostic Lab Data: unknown
CDC 'Split Type':

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


Changed on 5/14/2021

VAERS ID: 963016 Before After
VAERS Form:2
Age:65.0
Sex:Female
Location:Pennsylvania
Vaccinated:2021-01-14
Onset:2021-01-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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: unknown
Current Illness: denied ill symtpoms at time of vaccination
Preexisting Conditions: denied
Allergies: unknown. Denied allergies on vaccine form form
Diagnostic Lab Data: unknown
CDC 'Split Type':

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

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