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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1052226



Case Details

VAERS ID: 1052226 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-11
Onset:2021-02-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cyanosis, Death, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alveso, Xopenex, Aspirin, Atorvastatin, Cetirizine, Fiber, Hydralazine, Hydrochlorothiazide, Levothyroxine, Lisinopril, Meloxicam, Metformin, Metoprolol, Novolin,
Current Illness:
Preexisting Conditions: Arthritis, Diabetes Mellitus, Diabetic Neuropathy, Venous Insufficiency in Lower Extremity, Hypothyroidism, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Obesity
Allergies: Bactrim
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient discovered unresponsive in cell, blue coloration to skin, vital signs, undetectable. CPR initiated, Ambulance summoned. Following EMS arrival with additional unsuccessful attempts to revive patient, patient was determined to have expired.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1052226

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