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This is VAERS ID 970495

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 970495
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-13
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Sudden cardiac death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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:
Current Illness:
Preexisting Conditions: Hypertension, Diabetes Type 2, cardiac disease.
Allergies:
Diagnostic Lab Data: Unknown.
CDC 'Split Type':

Write-up: Patient expired three days after receiving first dose of Moderna COVID-19 vaccine. The death certificate states cause of death is sudden cardiac arrest.


Changed on 5/7/2021

VAERS ID: 970495 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-13
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Sudden cardiac death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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:
Current Illness:
Preexisting Conditions: Hypertension, Diabetes Type 2, cardiac disease.
Allergies:
Diagnostic Lab Data: Unknown.
CDC 'Split Type':

Write-up: Patient expired three days after receiving first dose of Moderna COVID-19 vaccine. The death certificate states cause of death is sudden cardiac arrest.


Changed on 5/21/2021

VAERS ID: 970495 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:North Carolina
Vaccinated:2021-01-13
Onset:2021-01-16
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Sudden cardiac death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-16
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:
Current Illness:
Preexisting Conditions: Hypertension, Diabetes Type 2, cardiac disease.
Allergies:
Diagnostic Lab Data: Unknown.
CDC 'Split Type':

Write-up: Patient expired three days after receiving first dose of Moderna COVID-19 vaccine. The death certificate states cause of death is sudden cardiac arrest.

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