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

This is VAERS ID 1024627

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Case Details

VAERS ID: 1024627 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died


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