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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1454388

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Case Details

VAERS ID: 1454388 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-23
Onset:2021-04-01
Submitted: 0000-00-00
Entered: 2021-07-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Computerised tomogram, Death, Herpes zoster, Laboratory test, Magnetic resonance imaging, X-ray
SMQs:, Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-04
   Days after onset: 64
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: High Blood Pressure, Cholesterol, Diabetes, anti-depressants medications (known)
Current Illness: none (known)
Preexisting Conditions: high blood pressure, cholesterol, type 2 diabetes
Allergies: unknown
Diagnostic Lab Data: labs, cat scans, MRIs, X-rays.
CDC Split Type:

Write-up: Singles virus broke out within one week of receiving the 2nd COVID-19 vaccination shot. The patient reported to Dr who was then given 400 mg of anti-virals medication. Patient did not improve and was taken to Hospital on 5/17/2021. The Patient was transferred to Hospital on 5/26/2021 and then died on 6/4/2021.


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