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This is VAERS ID 979796

History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 979796
VAERS Form:2
Age:74.0
Sex:Male
Location:Texas
Vaccinated:2021-01-08
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Adverse event

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: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021


Changed on 2/4/2021

VAERS ID: 979796 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Texas
Vaccinated:2021-01-08
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Adverse event

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: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021


Changed on 5/7/2021

VAERS ID: 979796 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Texas
Vaccinated:2021-01-08
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Pharmacy      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: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021


Changed on 5/14/2021

VAERS ID: 979796 Before After
VAERS Form:2
Age:74.0
Sex:Male
Location:Texas
Vaccinated:2021-01-08
Onset:2021-01-10
Submitted:0000-00-00
Entered:2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Pharmacy      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: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=979796&WAYBACKHISTORY=ON


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