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

This is VAERS ID 1085302



Case Details

VAERS ID: 1085302 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-26
Onset:2021-03-01
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Mechanical ventilation, Metabolic encephalopathy
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1085302

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