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This is VAERS ID 982942

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 982942
VAERS Form:2
Age:57.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: peanuts
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: per recipient spouse - vaccine recipient became ill during the night of 1/21/21 or early morning of 1/22/21 and was deceased in the morning of 1/22/21.


Changed on 5/7/2021

VAERS ID: 982942 Before After
VAERS Form:2
Age:57.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: peanuts peanuts
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: per recipient spouse - vaccine recipient became ill during the night of 1/21/21 or early morning of 1/22/21 and was deceased in the morning of 1/22/21.


Changed on 5/21/2021

VAERS ID: 982942 Before After
VAERS Form:2
Age:57.0
Sex:Male
Location:Arizona
Vaccinated:2021-01-21
Onset:2021-01-21
Submitted:0000-00-00
Entered:2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Death, Illness

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: peanuts peanuts
Diagnostic Lab Data: unknown
CDC 'Split Type':

Write-up: per recipient spouse - vaccine recipient became ill during the night of 1/21/21 or early morning of 1/22/21 and was deceased in the morning of 1/22/21.

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