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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1112123



Case Details

VAERS ID: 1112123 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Utah  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   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: Aspirin, Vit C, Coreg, Excitalopram, Ferrous Sulfate, Pravastatin, Senna Plus, Torsemide
Current Illness: CKD, muscle weakness, Heart Failure, CAD, Diabetes, HTN, Hyperlipidema, Palliative Care
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: This patient was on hospice, we are reporting this to VAERS at the Medical Directors request d/t patient''s death within 48 hours of the second dose vaccine. The death occurred the morning following his second dose of the Moderna COVID-19 Vaccination, vaccine received on 03/11/21 and patient date of death 03/12/21 at 9:41 am. This was a hospice patient with a terminal dx of CKD. This is being reported at the request of the Medical Director for the hospice team, d/t the patient''s death occurred within 48 hours of receiving the second dose of this vaccine. The nurse case manager stated the pt was declining as they were on hospice for a terminal condition and had co-morbidities, Pt did show more decline after receiving COVID-19 vaccination and patient passed away within 48 hours of receiving second vaccination dose.


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