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

This is VAERS ID 1122393



Case Details

VAERS ID: 1122393 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-18
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cheyne-Stokes respiration, Death, Diet refusal, General physical health deterioration
SMQs:, Acute central respiratory depression (broad), Respiratory failure (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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Around the end of January 2021, patient was admitted to a home hospice program due to worsening of patient''s Parkinson''s Disease and Dementia. It was noted on the hospice programs Plan of Care that patient had severe, progressive dysphagia due to disease. Patient lost 20 pounds over the last 2 months prior to admission to hospice program. Patient had severe tremors, dystonia, and was dyspneic with minimal exertion. Patient received Moderna''s Covid vaccine on 3/3/21. On 3/13/21, patient got progressively worse. He stopped eating and drinking and started to exhibit Cheyne-Stokes breathing. Hospice nurse noted that patient only had a few days remaining. On 3/18/21, patient passed away.


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