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

This is VAERS ID 1103192



Case Details

VAERS ID: 1103192 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-09
Onset:2021-03-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   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: Baclofen 10 mg, diazepam 5 mg, Meloxican 15 mg, Omeprazole 20 mg, hydromorphone 4 mg.
Current Illness: Chronic pain and neurologic dysfunction due to multiple traumas
Preexisting Conditions: Pain and neurologic dysfunction
Allergies: No known allergies
Diagnostic Lab Data: No autopsy will be performed per coroner. Dr. documented death certificate as natural causes
CDC Split Type:

Write-up: Patient passed in his sleep 5 days after receiving first dose of Moderna


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1103192

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