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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1027300



Case Details

VAERS ID: 1027300 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-06
Onset:2021-02-11
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None known
Preexisting Conditions: Aortic aneurysm, aortic stenosis, CAD, HTN, CHF, A-Fib, HLD, Ischemic heart failure, pacemaker, V-Fib, PVD, palpitations, hypotension, and small bowel obstruction.
Allergies: Unknown
Diagnostic Lab Data: None known.
CDC Split Type:

Write-up: Nausea, vomiting and generalized weakness.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1027300

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