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

This is VAERS ID 1088287



Case Details

VAERS ID: 1088287 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-09
Onset:2021-03-05
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Disorientation, Feeling abnormal, Respiratory disorder
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Temazepan 30 mg, Dexin, Bupropion, Sertraline 50 mg, Clonazepam, Difenhidramina 50mg, Valsartaan, Metroprolol, Omega 3, Nifedipine
Current Illness: None
Preexisting Conditions: High blood pressure, Alzheimer, cardiovascular disease, had suffer from heart failure
Allergies: None were reported
Diagnostic Lab Data:
CDC Split Type:

Write-up: The caregiver on duty tells the nurse in charge that on 5/3/2021 she proceeds to bathe the resident and he was disoriented, so she goes to bed at around 5:00 a.m. The resident expresses that he feels bad, when the caregiver goes to look for things to take vital, when he returns she finds him without vital signs and was presenting respiratory problems.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1088287

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