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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1023791

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Case Details

VAERS ID: 1023791 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Escitalopram Oxalate,amlodipine,aspirin,cyanocobalamin,docusate sodium,ergocalciferol,evothyroxine,Melatin,multivitamin,pravastatin,loratadine,senna,Protonix,carvedilol,Lokelma,lidocaine adhesive patch,buprenorphine ,hydralazine,Miralax,hy
Current Illness: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Preexisting Conditions: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Allergies: methadone, morphine, nortriptyline
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DIED WITHIN 5 DAYS OF RECEIEVING THE 2ND DOSE, EXPERIENCED GENERALIZED WEAKNESS.


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