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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1152975



Case Details

VAERS ID: 1152975 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-02-25
Onset:2021-03-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042722 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Malaise, Oxygen saturation, Oxygen saturation decreased, Pyrexia, SARS-CoV-2 test
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CLOPIDOGREL; FUROSEMIDE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Date: 20210304; Test Name: Oxygen saturation; Result Unstructured Data: Decreased; Test Date: 20210305; Test Name: COVID-19 PCR test; Test Result: Negative ; Result Unstructured Data: Covid PCR test; Test Date: 20210304; Test Name: COVID-19 rapid POC test; Test Result: Negative ; Result Unstructured Data: Covid test
CDC Split Type: NLMODERNATX, INC.MOD20210

Write-up: Death; oxygen saturation decreased; A regulatory authority report was received from a physician, concerning an 81 year-old male patient, who was administered Moderna''s COVID-19 vaccine (mRNA-1273), and experienced oxygen saturation decreased, malaise (malaise), asthenia, and pyrexia and subsequently died (Death). The patient''s medical history was not reported. Concomitant medications reported included clopidogrel, and furosemide. On 25 Feb 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (batch number: 300042722), intramuscularly for the prophylaxis of COVID-19 infection. On 04 Mar 2021, the patient experienced oxygen saturation decreased, malaise, asthenia and pyrexia. On the same day, the patient underwent COVID-19 rapid point-of care (POC) test which was negative. On 05 Mar 2021, the patient underwent COVID-19 polymerase chain reaction (PCR) test which was negative. On 07 Mar 2021, the patient died. Cause of death was not reported. Plans for an autopsy were unknown. No treatment information was reported. Action taken with second dose of mRNA-1273 in response to the events was not applicable. The outcomes of the events, oxygen saturation decreased, malaise, asthenia and pyrexia, were unknown.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events (oxygen saturation decreased, malaise, asthenia and pyrexia), a causal relationship cannot be excluded. Very limited information regarding this patient''s death has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


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