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

This is VAERS ID 1047634



Case Details

VAERS ID: 1047634 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, SARS-CoV-2 test positive, Urinary tract infection
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to hospital on 2-9-21 for urinary tract infection and tested positive for Covid. Developed pneumonia and expired on 2-12-21.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1047634

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