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

This is VAERS ID 1101837



Case Details

VAERS ID: 1101837 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Malaise
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient Medication List: tacrolimus, mycophenolic acid, prednisone, clonidine, coumadin, vascepa, carbamazepine, vitamin d3, hydroxyzine, nifedipine, carvedilol, rosuvastatin, sodium bicarb, pioglitazone, lantus, humalog, lisinopril.
Current Illness: Dehydration 2 days prior, treatted by Hospital
Preexisting Conditions: Kidney failure and resulting transplant, IDDM, hyperlipidemia, Htn
Allergies: Seasonal allergies only
Diagnostic Lab Data: See medical records for details.
CDC Split Type:

Write-up: The patient became ill two days after the vaccination, and was hospitalized. He was diagnosed with COVID pneumonia on the 15th, and subsequently died.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1101837

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