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

This is VAERS ID 1039304



Case Details

VAERS ID: 1039304 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Gastrointestinal tube insertion, Pneumonia, Respiratory tract congestion, SARS-CoV-2 test negative, White blood cell count increased
SMQs:, Acute renal failure (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC Split Type:

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1039304

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