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This is VAERS ID 974033

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 974033
VAERS Form:2
Age:69.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-13
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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: coronary artery disease, diabetes mellitus, hypertension, TIA, asthma, CVA stroke, anemia, peripheral neuropathy, heart failure, heart disease with congestion
Allergies: Macrobid, depacote, sulfamethoxazole/trimethorpim, lisinopril, lyrica, sumatriptan succinate
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident deceased on 1/26 at 445am. No signs ahead of time.


Changed on 5/7/2021

VAERS ID: 974033 Before After
VAERS Form:2
Age:69.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-13
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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: coronary artery disease, diabetes mellitus, hypertension, TIA, asthma, CVA stroke, anemia, peripheral neuropathy, heart failure, heart disease with congestion
Allergies: Macrobid, depacote, sulfamethoxazole/trimethorpim, lisinopril, lyrica, sumatriptan succinate succinate
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident deceased on 1/26 at 445am. No signs ahead of time.


Changed on 5/14/2021

VAERS ID: 974033 Before After
VAERS Form:2
Age:69.0
Sex:Female
Location:Indiana
Vaccinated:2021-01-13
Onset:2021-01-26
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-26
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: coronary artery disease, diabetes mellitus, hypertension, TIA, asthma, CVA stroke, anemia, peripheral neuropathy, heart failure, heart disease with congestion
Allergies: Macrobid, depacote, sulfamethoxazole/trimethorpim, lisinopril, lyrica, sumatriptan succinate succinate
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident deceased on 1/26 at 445am. No signs ahead of time.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=974033&WAYBACKHISTORY=ON


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