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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1341218



Case Details

VAERS ID: 1341218 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-19
Onset:2021-02-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 AR / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 AR / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Epidural analgesia, Inflammation, Magnetic resonance imaging, Sciatica
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 74
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram, Simvastin, Eliquis, Lisinoprel, Vit d3,
Current Illness: None
Preexisting Conditions: Spinal stenosis.
Allergies: None
Diagnostic Lab Data: MRI, epidural, multiple interventions of PT, Chiropractor, medications, etc.
CDC Split Type:

Write-up: Within hours of receiving the second Moderna vaccine, the patient began experiencing excruciating pain in his lower back and sciatica. Consensus among the health professionals he saw is that the second vaccine triggered an inflammatory response. The pain did not respond to medication physical therapies.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1341218

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