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

This is VAERS ID 1227320



Case Details

VAERS ID: 1227320 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-16
Onset:2021-01-18
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac stress test normal, Chest pain, Death, Dizziness, Electrocardiogram normal, Fatigue, Feeling abnormal, Malaise, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Losartan Potassium 25mg, Azithromycin and Amlodipine Besylate
Current Illness: Had severe Covid in June 2020 but cleared after one month.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: about 2 days after the 1st dose of the moderna vaccine, felt very tired and unwell for several days. He felt okay for about 2 weeks then on January 29, 2021 he felt intense chest pain. Concerned it was a heart attack, he was brought to the hospital. He stayed one night and the hospital ran several tests like EKG, stress test and others. Found his results to be normal and was released on January 20, 2021. Even the moment he was released, he felt very dizzy but hospital was not concerned and thought maybe side effect of medication. He continued to feel dizzy, fuzzy brain and hard time staying awake during the day and sleeping through the night for the rest of the week. He passed sometime in the early hours of February 6, 2021. Doctor''s suspicion is a blood clot. He has no history of blood clots, heart problems or any health issues.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1227320

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