VAERS ID: 936805

AGE: 25| SEX: M|STATE: KY (United States)

Description

Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21.

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Symptoms

Unresponsive to stimuli, Death

Vaccines

VAX DATE: 12-22-2020| ONSET DATE: 01-11-2021| DAYS TO ONSET: 20
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 1 COVID19 MODERNA 039k20a IM RA

RECVDATE:01-12-2021
RPT_DATE:
CAGE_YR:25
CAGE_MO:
DIED:Y
DATEDIED:01-11-2021
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:N
LAB_DATA:None associated.
V_ADMINBY:PVT
OTHER_MEDS:See Continuation Field
CUR_ILL:Whiplash injury to neck. Sprain of ligaments of cervical spine
HISTORY:Septal defect (heart), chronic sinusitis
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:01-11-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:Ceftriaxone
V_FUNDBY:

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