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This is VAERS ID 991080

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 991080
VAERS Form:2
Age:69.0
Sex:Male
Location:Massachusetts
Vaccinated:2020-12-28
Onset:2021-01-06
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Sudden death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient sudden death reported by family. No further details available at this time.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=991080&WAYBACKHISTORY=ON


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