National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 991927

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 991927
VAERS Form:2
Age:86.0
Sex:Male
Location:North Dakota
Vaccinated:2021-01-05
Onset:2021-01-12
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-12
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: Diphenhydramine HCl, atorvastatin, furosemide, gabapentin, Healthy Eyes (vitamin A, C, & E with lutein minerals), Imodium, Isosorbide mononitrate, Jantoven, Potassium Cl, Metoprolol succinate, Nitroglycerin.
Current Illness:
Preexisting Conditions: Constipation, acute exacerbation of chronic congestive heart failure , osteoarthritis, mitral and aortic incompetence, abnormal renal function, hernia of abdominal cavity, polyp of colon, coronary arteriosclerosis, atrial fibrillation, aortic valve stenosis, aortic valve disorder, cerebrovascular disease, long term current use of anticoagulant, sick sinus syndrome, edema, gout, angina co-occurrent and due to coronary arteripolyneuropathy, essential hypertension, mixed hyperlipidemia, chronic kidney disease stage 3, chronic systolic heart failure, angina, prosthetic cardiac paravalvular leak, prosthetic heart valve in situ, aortic stenosis-non-rheumatic, macrocytic anemia, diarrhea-occasionally, heart disease, cerebrovascular accident, old MI, Squamous cells carcinoma of skin of face, long QT syndrome- 6/18/2020 PPM placed.
Allergies: No known defined allergies.
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found deceased at Nursing Home in his room 01/12/2021 at 5:25 AM.

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=991927&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166