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

This is VAERS ID 1236419



Case Details

VAERS ID: 1236419 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Hypophagia, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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, that is a facility resident, received his Moderna covid vaccine #1 on 12/28/20. On 1/14/21 due a continued decline in status, he was changed to hospice care. On 1/25/21, he received covid #2. He was noted to have a decline in oral intake and increase in somnolence over a few weeks prior to his date of death on 2/9/21. No autopsy results available. 15 days from date of second vaccine to date of death.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1236419

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