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This is VAERS ID 997297

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 997297
VAERS Form:2
Age:85.0
Sex:Male
Location:Tennessee
Vaccinated:2021-01-04
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Public      Purchased by: ??
Symptoms: Death, Pneumonia, Septic shock, Urinary tract infection, Chronic kidney disease

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-17
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death on 1/17/21. Death certificate reports: Septic Shock, UTI, Pneumonia, Chronic Renal Failure

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