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

This is VAERS ID 1236418



Case Details

VAERS ID: 1236418 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-02-10
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 13L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received Moderna covid #1 on 1/14/21. On 1/29/21, a social worker note was placed that indicated that patient was now under home hospice care. No scanned records on file. No further notes regarding events from this time to date of death on 2/10/21. No autopsy results available. 27 days from date of vaccine to date of death.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1236418

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