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This is VAERS ID 986857

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 986857
VAERS Form:2
Age:66.0
Sex:Male
Location:Texas
Vaccinated:2020-12-28
Onset:2020-12-28
Submitted:0000-00-00
Entered:2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Nausea, Mental status changes

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.


Changed on 5/7/2021

VAERS ID: 986857 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Texas
Vaccinated:2020-12-28
Onset:2020-12-28
Submitted:0000-00-00
Entered:2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Nausea, Mental status changes

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood seafood
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.


Changed on 5/21/2021

VAERS ID: 986857 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Texas
Vaccinated:2020-12-28
Onset:2020-12-28
Submitted:0000-00-00
Entered:2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Nausea, Mental status changes

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood seafood
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=986857&WAYBACKHISTORY=ON


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