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This is VAERS ID 979155

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 979155
VAERS Form:2
Age:65.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-03
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Chills, Headache, Neck pain, Vomiting, Influenza A virus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T
Current Illness:
Preexisting Conditions: Heart Disease, Polyneuropathy, Anemia and chronic Kidney disease, Type 2 Diabetes, hypotension
Allergies:
Diagnostic Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A
CDC 'Split Type':

Write-up: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,


Changed on 5/7/2021

VAERS ID: 979155 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-03
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Chills, Headache, Neck pain, Vomiting, Influenza A virus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T
Current Illness:
Preexisting Conditions: Heart Disease, Polyneuropathy, Anemia and chronic Kidney disease, Type 2 Diabetes, hypotension
Allergies:
Diagnostic Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A
CDC 'Split Type':

Write-up: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,


Changed on 5/21/2021

VAERS ID: 979155 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-03
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / UN

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Chills, Headache, Neck pain, Vomiting, Influenza A virus test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T
Current Illness:
Preexisting Conditions: Heart Disease, Polyneuropathy, Anemia and chronic Kidney disease, Type 2 Diabetes, hypotension
Allergies:
Diagnostic Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A
CDC 'Split Type':

Write-up: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,

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