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

This is VAERS ID 1108476



Case Details

VAERS ID: 1108476 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-06
Onset:2021-02-10
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute myocardial infarction, Cardiac failure acute, Cardiac failure congestive, Condition aggravated, Cough, Death, Malaise, Pneumonia
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Dose #1 of vaccine was administered 2/6/21, per daughter''s report patient became ill 3 days later (cough) and was taken to local hospital and was discharged with diagnosis of CAP, NSTEMI and acute on chronic CHF exacerbation. Discharged home on hospice where he passed away at home on 2/20/21.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1108476

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