Adverse Event Reporting

VAERS ID 924186
Gender Female
Age 91
StateCode MI
Pharmaceutical Company MODERNA
Lot Number 025J20A
Number of vaccinations 1
Vaccinated 2020-12-30
Onset 2021-01-03
Condition Died
  • Death

Current Illness

Covid positive previous with no s/s poor appetite Chronic wound right leg

Preexisting Conditions

alzheimers dementia, COPD , DM- type 2

Other Medications

aldactone, lasix, aspirin, tylenol, potassium, spiriva

Previous Vaccinations


Codeine, Penicillin, Sulfa

Laboratory Data


Resident expired 1/3/21