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

This is VAERS ID 1371354



Case Details

VAERS ID: 1371354 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-15
Onset:2021-04-26
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Chills, Death, Decreased appetite, Dizziness, Dyspnoea, Oropharyngeal pain, Pain, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None
Preexisting Conditions: Smoker
Allergies: N/A
Diagnostic Lab Data: Symptoms began on April 26. Contacted doctor on Wednesday, April 28 and appointment was made for Tuesday May 4. He died the day before his appointment, May 3.
CDC Split Type:

Write-up: Patient developed dizziness, chills, fever, body ache, sore throat, difficulty breathing, and stopped eating beginning April 26, The adverse effect is the belief that a breakthrough case of Covid-19 will be less severe if you had the shots. A false sense of security.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1371354

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