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

This is VAERS ID 1223167



Case Details

VAERS ID: 1223167 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-13
Onset:2021-03-05
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Military       Purchased by: ?
Symptoms: Balance disorder, Death, Endotracheal intubation, General physical health deterioration, Memory impairment, Neurological symptom, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Angioedema (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 23 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: a-fib medication, COPD medication, anti-depressants
Current Illness: none that I know of
Preexisting Conditions: COPD, heart issues
Allergies: none that I know of
Diagnostic Lab Data:
CDC Split Type:

Write-up: My father received the first dose on 2/13, and started to rapidly decline thereafter. He started having neurological issues, memory issues, and balance issues and eventually collapsed and was hospitalized on 3/5, intubated twice in two weeks, with his death occurring on 3/31/21.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1223167

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