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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1019964

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Case Details

VAERS ID: 1019964 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-07
Onset:2021-02-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ferrous sulfate, Proteinex, Tylenol, Eliquis, Aspirin, Lipitor, Vitamin D3, Cholestyramine, finasteride, flavoxate, lactobacillus, loratadine, magnesium oxide, metoprolol, protonix, miralax, potassium cl, Tamsulosin, acetic acid (for foley)
Current Illness: Peg tube placement Malignant neoplasm of esophagus
Preexisting Conditions: Attention and concentration deficit, Hyperlipidemia, Acute embolism thrombosis of Deep veins or upper extremity, cognitive communication deficit, cerebral infarction, Dysphagia, Thrombocytopenia, Obstructive and reflux uropathy, Hypomagnesemia, Allergic rhinitis, GERD, Hydronephrosis with renal and ureteral calculous obstruction, Benign prostatic hyperplasia with lower urinary tract symptoms, anemia, ulcerative pancolitis, cerebral cysts, chronic obstructive pyelonephritis, hypo-osmolality and hyponatremia, HTN, Vascular dementia with behavioral disturbances, DM II, Moderate protein-calorie malnutrition, Vitamin D deficiency, Folliculitis, Hypokalemia, Aphasia following cerebral infarction, metabolic syndrome
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: The resident received his COVID-19 Moderna vaccination on 2/6/2021 2:11 pm and expired on 2/7/2021 at 6:04 am. There were no signs or symptoms of vaccination reaction leading up to death.


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