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

This is VAERS ID 1220532



Case Details

VAERS ID: 1220532 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-03-14
Onset:2021-03-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1220532

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