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This is VAERS ID 970930

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 970930
VAERS Form:2
Age:91.0
Sex:Male
Location:North Carolina
Vaccinated:2021-01-09
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Fall, Head injury, Respiratory disorder, COVID-19, SARS-CoV-2 test positive, SARS-CoV-2 antibody test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: I-caps
Current Illness: -
Preexisting Conditions: AAA
Allergies: Penicillins
Diagnostic Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.
CDC 'Split Type':

Write-up: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.


Changed on 5/7/2021

VAERS ID: 970930 Before After
VAERS Form:2
Age:91.0
Sex:Male
Location:North Carolina
Vaccinated:2021-01-09
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Fall, Head injury, Respiratory disorder, COVID-19, SARS-CoV-2 test positive, SARS-CoV-2 antibody test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: I-caps
Current Illness: -
Preexisting Conditions: AAA
Allergies: Penicillins Penicillins
Diagnostic Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.
CDC 'Split Type':

Write-up: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.


Changed on 5/21/2021

VAERS ID: 970930 Before After
VAERS Form:2
Age:91.0
Sex:Male
Location:North Carolina
Vaccinated:2021-01-09
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Death, Fall, Head injury, Respiratory disorder, COVID-19, SARS-CoV-2 test positive, SARS-CoV-2 antibody test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: I-caps
Current Illness: -
Preexisting Conditions: AAA
Allergies: Penicillins Penicillins
Diagnostic Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.
CDC 'Split Type':

Write-up: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=970930&WAYBACKHISTORY=ON


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