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This is VAERS ID 963163

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 963163
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-06
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative:


Changed on 5/7/2021

VAERS ID: 963163 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-06
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative:


Changed on 5/14/2021

VAERS ID: 963163 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-06
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Narrative:

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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=963163&WAYBACKHISTORY=ON

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