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This is VAERS ID 967506

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 967506
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-16
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Died within 5 days of receiving vaccine. Exact cause and day unknown.


Changed on 5/7/2021

VAERS ID: 967506 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-16
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Died within 5 days of receiving vaccine. Exact cause and day unknown.


Changed on 5/14/2021

VAERS ID: 967506 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Texas
Vaccinated:2021-01-16
Onset:2021-01-01
Submitted:0000-00-00
Entered:2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / -

Administered by: Unknown      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Died within 5 days of receiving vaccine. Exact cause and day unknown.

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