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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1107656



Case Details

VAERS ID: 1107656 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-03
Onset:2021-03-15
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   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: Abilify 10mg daily Bumex 1mg daily B12 injection monthly Wellbutrin xl 300mg daily Cardizem 30mg three times daily levothyroxine 200mcg daily metoprolol 50mg twice a day multivitamin xarelto 20mg daily Butrans 15mcg/hr patch weekly midodrin
Current Illness: Unknown
Preexisting Conditions: congestive heart failure with reduced EF atrial fibrillation sleep apnea acute kidney injury anemia chronic pain depression
Allergies: no known allergies
Diagnostic Lab Data: determined to be natural causes, thought to be due to heart failure
CDC Split Type:

Write-up: Patient was found dead on 3/15/2021


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