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From the 4/8/2021 release of VAERS data:

This is VAERS ID 1030712



Case Details

VAERS ID: 1030712 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Decreased appetite, Depressed level of consciousness, Fatigue, Food refusal, Loss of consciousness, Pyrexia, Respiratory rate increased
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1030712


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