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

This is VAERS ID 1041333



Case Details

VAERS ID: 1041333 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-05
Onset:2021-02-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bedridden, Dysphagia, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Lorazepam, Seroquel, Trileptal, Senna Plus, Acetaminophen, Aspirin, Buspar, Sinemet, Cyanocobalamin, Depakote, Aricept, Pepcid, Hydrochlorothiazide, Provera, Melatonin, Namenda, Dolophine, Milk of Magnesia, Morphine, Omeprazole, Sorbitol, F
Current Illness: End stage Dementia, End stage Parkinson''s Disease, on Hospice care. Dependent in all cares, non-verbal.
Preexisting Conditions: End stage Dementia, End stage Parkinson''s Disease, on Hospice care
Allergies: Penicillin, Vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: He developed a fever on 1/8, become unable to swallow and bedbound. He was already end of life and Hospice care at the time of the vaccine.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1041333

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