VAERS ID: 913143

AGE: 84| SEX: F|STATE: TX (United States)

Description

Vaccine administered with no immediate adverse reaction at 11:29am. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 1:30pm the resident passed away.

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Symptoms

Death

Vaccines

VAX DATE: 12-29-2020| ONSET DATE: 12-29-2020| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH EL0140 IM LA

RECVDATE:12-29-2020
RPT_DATE:
CAGE_YR:84
CAGE_MO:
DIED:Y
DATEDIED:12-29-2020
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:
V_ADMINBY:SEN
OTHER_MEDS:Gabapentin 100mg, Memantine 10mg
CUR_ILL:
HISTORY:dementia, aphasia, type 2 DM, iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, MDD
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:12-29-2020
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:codeine, phenobarbital, penicillin
V_FUNDBY:

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