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

This is VAERS ID 1371446



Case Details

VAERS ID: 1371446 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-08
Onset:2021-05-14
   Days after vaccination:67
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Lung disorder, Pneumonitis, Pulmonary granuloma, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Interstitial lung disease (narrow), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-20
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted for syncopal episode on 5/14/21, found to have lung lesion with necrotizing granulomatous inflammation, deceased 5/20/21


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