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

This is VAERS ID 1228372



Case Details

VAERS ID: 1228372 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-12
Onset:2021-04-14
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Incomplete course of vaccination
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   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: Yes but unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife called in mid March 2021 letting us know that the patient, needed to re-schedule his 2nd dose of Moderna Covid-19 vaccine - he had missed his scheduled 2nd dose date due to being hospitalized - doctors had thought he might need a defibrillator but then discharged him without one. Patient''s wife called back on 4/16 to let us know that he passed away on 4/14.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1228372

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