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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1111042



Case Details

VAERS ID: 1111042 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-10
Onset:2021-03-15
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pain in extremity, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad)

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: Atorvastin, Lantus, Bacid, Ferrous Sulfate, Flomax, Gabapentin, Lasix, Metoprolol, Norvasc, Duloxatine
Current Illness: None, admitted to this facility on 2/4/21. Recently declining condition, decreased appetite.
Preexisting Conditions: DM, Unspecified behavioral syndromes associated w/ physiological disturbances and physical factors, CAD, HTN, Chronic pain syndrome, physical deconditioning, anemia, CKD, hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: RHC 3/15/21. No significant reaction from vaccine. Had sore arm.


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