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This is VAERS ID 979081

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 979081
VAERS Form:2
Age:89.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix
Current Illness: None
Preexisting Conditions: Acute systolic congestive heart failure, Atrial Fibrillation, Coronary Artery Disease, Left Ventricular Hypertrophy, Arteriosclerotic Heart Disease, Carotid Artery Stenosis, Ischemic Cardiomyopathy, Hypertension, Osteoarthritis, Myelodysplasia, COPD, Dyslipidemia, Malignant Neoplasm of Colon, Anemia
Allergies: NKA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.


Changed on 5/7/2021

VAERS ID: 979081 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix
Current Illness: None
Preexisting Conditions: Acute systolic congestive heart failure, Atrial Fibrillation, Coronary Artery Disease, Left Ventricular Hypertrophy, Arteriosclerotic Heart Disease, Carotid Artery Stenosis, Ischemic Cardiomyopathy, Hypertension, Osteoarthritis, Myelodysplasia, COPD, Dyslipidemia, Malignant Neoplasm of Colon, Anemia
Allergies: NKA NKA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.


Changed on 5/21/2021

VAERS ID: 979081 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:California
Vaccinated:2021-01-21
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix
Current Illness: None
Preexisting Conditions: Acute systolic congestive heart failure, Atrial Fibrillation, Coronary Artery Disease, Left Ventricular Hypertrophy, Arteriosclerotic Heart Disease, Carotid Artery Stenosis, Ischemic Cardiomyopathy, Hypertension, Osteoarthritis, Myelodysplasia, COPD, Dyslipidemia, Malignant Neoplasm of Colon, Anemia
Allergies: NKA NKA
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.

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