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

This is VAERS ID 1368553



Case Details

VAERS ID: 1368553 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-08
Onset:2021-05-16
   Days after vaccination:97
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Agonal respiration, Bilevel positive airway pressure, COVID-19 pneumonia, Cardio-respiratory arrest, Cough, Dyspnoea, Endotracheal intubation, Fibrin D dimer increased, General physical health deterioration, Intensive care, Life support, Oxygen saturation decreased, Pain, Procalcitonin increased, Pulseless electrical activity, Pyrexia, Serum ferritin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: lyrica, ASA, sertraline, Sevelamer, insulin Lispro, insulin lantus, lipitor,
Current Illness: unknown
Preexisting Conditions: cardiac stent x3, CHF, HTN, ESRD, neuropathy, Diabetes mellitus
Allergies: Actos- diarrhea tramadol-hallucinations Tape- rash
Diagnostic Lab Data: 5/27- PCT 8.22 ng/ml, Ddimer 5227, ferrit $g1500.
CDC Split Type:

Write-up: 5/16- symptoms started- cough, fever body aches. admitted 5/19 with SOB in addition. COVID pnuemonitis, 5/23-sudden decrease in saturation - placed on BiPAP and transferred to the ICU. further decline and arrested on 5/27. PEA and agonal breathing. intubated and ACLS meds given. Coded a second time and family elected to halt heroic measures.


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