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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1123229



Case Details

VAERS ID: 1123229 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-05
Onset:2021-03-08
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Confusional state, Death, Influenza, Influenza B virus test positive, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 4
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: NONE REPORTED
Preexisting Conditions: TYPE II DIABETES; HYPERTENSION; DEMENTIA; HEPERLIPIDEMIA; HX OF PROSTATE CANCER
Allergies: NKA
Diagnostic Lab Data: On admission to the hospital the patient was antigen positive for COVID and Influenza B positive. Death was related to COVID Pneumonia per reports.
CDC Split Type:

Write-up: Patient received Moderna Dose #1-01/08/2021 and Dose #2-02/05/2021. He was admitted to Medical Center on 03/08/2021 with confusion and decreased O2 sats; date of death was 03/12/2021.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1123229

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