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

This is VAERS ID 1226364



Case Details

VAERS ID: 1226364 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-03-05
Onset:2021-03-16
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A221A / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Pneumonia, Troponin increased, Vaccination complication
SMQs:, Myocardial infarction (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Date of the first vaccination was 2/5/2021. On 2/23/2021 patient developed shortness of breath. Patient had his 2nd vaccination scheduled on 3/5/2021. Prior to the 2nd evaluation, Patient was evaluated by his cardiologist who said his heart was functioning correctly to proceed with the 2nd vaccination.
Preexisting Conditions: heart disease, high blood pressure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed unspecified pneumonia which led to extremely high troponin levels. Patient died due to cardio pulmonary disease due to complications from COVID vaccine.


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