VAERS ID: 1078352

AGE: 18| SEX: M|STATE: IL (United States)

Description

Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home.

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Symptoms

Headache, Pain, Chest pain, Fatigue, Unresponsive to stimuli, Death

Vaccines

VAX DATE: 03-02-2021| ONSET DATE: 03-05-2021| DAYS TO ONSET: 3
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 1 COVID19 MODERNA 010A21A IM LA

RECVDATE:03-06-2021
RPT_DATE:
CAGE_YR:18
CAGE_MO:
DIED:Y
DATEDIED:03-05-2021
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:Medical examiner report is pending.
V_ADMINBY:PVT
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:03-06-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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