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From the 5/14/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 991677



Case Details

VAERS ID: 991677 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: diagnosed with Covid on 12/03/2020
Preexisting Conditions: hypertension, hyperlipidemia, diabetes, GERD
Allergies: Sulfa, Flexeril, trimethoprim
Diagnostic Lab Data:
CDC Split Type:

Write-up: got up in the night and stated that she couldn''t breath, ambulance was called, pt expired in route to hospital. *relayed to me by Facility staff RN.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=991677

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