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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1241676

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Case Details

VAERS ID: 1241676 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-26
Onset:2021-04-12
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate decreased, Hypotension, Respiratory disorder
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Omeprazol 20 mg, Isosorbide mononitrate, vitamina D3, Melatonina, Lasiz, Lurasidone -HCL, Eliquis, Atorvastatin, itamina B12, Divalpropex- NA, Metoprolol, eye drops.
Current Illness: Unknown.
Preexisting Conditions: Dementia, atrial fibrillation, arterial coronary disease, Alzheimer, mayor neurocognitive disorder, dysphagia, hyperlipidemia, hypertension, moderate depression.
Allergies: Unknown.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: The patient was with respiratory difficulties, low pressure and low pulse.


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