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

This is VAERS ID 1048917



Case Details

VAERS ID: 1048917 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram normal, Death, Fall, Laboratory test, White blood cell count increased, X-ray normal
SMQs:, Neuroleptic malignant syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG EC tablet 1 daily, Latanoprost 0.005% Ophth Soln, Incruse Ellip 62.5MCG/ACT Inh, , Losartan 25 MG tablet, Ompeprazole 20 mg, Potassium CL 20 MEQ ER tablet, Preservision Areds Tablet, Simvastatin 40 MG tablet,
Current Illness: No acute illness
Preexisting Conditions: Diagnosis Codes obtained upon admission in 11.17.2015 I45.10, J30.9, J44.9, E78.0, i10, K21.9, H40.9, D69.6, G93.40, K59.0, Z96.641, sm869, sm859
Allergies: Morphine, Shellfish
Diagnostic Lab Data: Tests ran at Hospital. Unsure of full tests and results. Only received updated from resident representative.
CDC Split Type:

Write-up: Resident yelling for assistance in apartment. Nursing personnel found resident on floor at 6:10 AM on 2/18/2021. Resident was transported to Hospital on 2/18/2021. Status update on 2/18/2021 from son, resident CT & X-rays were done all normal. Labs done and WBC count was elevated and awaiting results. Resident stable and admitted to hospital for observation. Resident passed away on 2.21.2021.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1048917

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