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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1024626



Case Details

VAERS ID: 1024626 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-01
Onset:2021-02-06
   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: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: amlodipine,aspirin,losartan,metformin,pravastatin,polyethylene glyco,Colace,cholecalciferol
Current Illness: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Preexisting Conditions: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 5TH DAY OF 2ND DOSE.


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