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

This is VAERS ID 1115944



Case Details

VAERS ID: 1115944 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-18
Onset:2021-03-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / N/A RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest pain, Death, Refusal of treatment by patient
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   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: Unknown
Current Illness: Unknown. On date of vaccination he stated he was not feeling ill/sick.
Preexisting Conditions: History of CVA with paralysis of face and arm and ischemic heart disease.
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 1-2 hours after receiving Moderna vaccination patient began complaining of chest pain to family members but refused to seek medical attention. He was found deceased this morning (03/19/21) by his family. Medical Examiner determined time of death was around 8:40pm on 03/18/21.


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