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

This is VAERS ID 1219828



Case Details

VAERS ID: 1219828 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-19
Onset:2021-03-01
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 44
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: levothyroxine, furosemide
Current Illness:
Preexisting Conditions:
Allergies: no known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his first Moderna vaccine 3-19-21. He was due for his 2nd dose 4-16-21. We followed up with his sister due to missed appointment and was informed that he passed away 4-15-21 due to a blood clot.


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