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

This is VAERS ID 1105146



Case Details

VAERS ID: 1105146 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-30
Onset:2021-01-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Productive cough, Resuscitation, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Keppra 1000 mg, Flexeril, Vitamins
Current Illness: None
Preexisting Conditions: Epilepsy, Hydrocephalus, and Multiple Sclerosis
Allergies: Not reported
Diagnostic Lab Data: None
CDC Split Type: PR-56-21

Write-up: 1/19 began vomiting and was hospitalized. On 1/30 he was discharged and later received the vaccine. It begins with weakness and a lack of appetite. He started coughing up foul-smelling secretions. He makes the arrangements to take him to the emergency room again, he called 911 to be transported, when they are taking the information from the POC, he is under oxygenation to 44. They take him in the ambulance, he receives CPR, they transport him to the facility where he arrives lifeless.


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