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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1242022

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Case Details

VAERS ID: 1242022 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-04-13
Onset:2021-04-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Cough, Death, Dyspnoea, Headache, Oropharyngeal pain
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: baclofen carbidopa/levodopa furosemide gabapentin lactulose rifaximin spironolactone tamsulosin vit B12 acetaminophen
Current Illness: alcoholic cirrhosis with ascites type 2 diabetes hyponatremia spinal stenosis vitamin B12 deficiency
Preexisting Conditions: see item 11
Allergies: no known allergies
Diagnostic Lab Data: None - my understanding is that autopsy will be done, medical examiner to determine cause of death.
CDC Split Type:

Write-up: Patient care coordinator on PCP team learned of patient death, as documented: TC to pt family for a welfare ck d/t co-worker mentioned saw in social media pt had passed? PCC-spoke with pt daughter states father passed on 4/18/2021 in the PM unknown exact time of death at home. PCC gave family condolences for their loss. Patient reports father got covid-19 vaccine on 4/13/2021 and he started having severe HA''s on this day. Sx increased for the next few days, he had dry cough,sore throat,chest pain,SOB. States father declined for family to called an ambulance while sx were increasing. States ambulance was called on Sunday 4/18/2021 to take body to the morgue. States they are awaiting for autopsy results,and death certificate. States father''s body will be taken to his family. On what date did they pass away? 418/2021 unknown time, at home Do you know what the cause was? Family is not sure of cause of death


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