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This is VAERS ID 971176

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 971176
VAERS Form:2
Age:84.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Death, Fatigue, Livedo reticularis, Malaise, Respiratory arrest, Vomiting, Autopsy

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: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter
Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up
Preexisting Conditions: BPH reflux (Gerd) Osteoarthritis high cholesterol
Allergies: none
Diagnostic Lab Data: Autopsy being done.
CDC 'Split Type':

Write-up: Pt. woke up the next morning after vaccination and "didn''t feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn''t breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.


Changed on 5/7/2021

VAERS ID: 971176 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Death, Fatigue, Livedo reticularis, Malaise, Respiratory arrest, Vomiting, Autopsy

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: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter
Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up
Preexisting Conditions: BPH reflux (Gerd) Osteoarthritis high cholesterol
Allergies: none none
Diagnostic Lab Data: Autopsy being done.
CDC 'Split Type':

Write-up: Pt. woke up the next morning after vaccination and "didn''t feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn''t breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.


Changed on 5/21/2021

VAERS ID: 971176 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-20
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Death, Fatigue, Livedo reticularis, Malaise, Respiratory arrest, Vomiting, Autopsy

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: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter
Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up
Preexisting Conditions: BPH reflux (Gerd) Osteoarthritis high cholesterol
Allergies: none none
Diagnostic Lab Data: Autopsy being done.
CDC 'Split Type':

Write-up: Pt. woke up the next morning after vaccination and "didn''t feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn''t breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.

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