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

This is VAERS ID 1178571



Case Details

VAERS ID: 1178571 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-12
Onset:2021-04-02
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Scan myocardial perfusion normal
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   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: Amlodipine, Gabapentin, Aspirin, Ramipril, Metoprolol, Atorvastatin
Current Illness: Gout, HTN, seizure disorder.
Preexisting Conditions: See above.
Allergies: Bee stings, NKDA.
Diagnostic Lab Data: Pt had had a cardiology visit 3/22. Ramipril rx was new. Perfusion test five months prior was negative for ischemia. Plan to see him back PRN basis.
CDC Split Type:

Write-up: Pt was found deceased at home, 4/2/2021.


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