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This is VAERS ID 969219

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 969219
VAERS Form:2
Age:61.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-23
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 7+ LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
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: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg
Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues
Preexisting Conditions: hypertensin gout
Allergies: no known allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon


Changed on 5/7/2021

VAERS ID: 969219 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-23
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 7+ LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
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: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg
Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues
Preexisting Conditions: hypertensin gout
Allergies: no known allergies allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon


Changed on 5/14/2021

VAERS ID: 969219 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-23
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 7+ LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-24
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: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg
Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues
Preexisting Conditions: hypertensin gout
Allergies: no known allergies allergies
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon

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