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

This is VAERS ID 1549226



Case Details

VAERS ID: 1549226 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-22
Onset:2021-05-17
   Days after vaccination:84
Submitted: 0000-00-00
Entered: 2021-08-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Ageusia, Anosmia, Chest X-ray abnormal, Chills, Cough, Death, Diarrhoea, Dyspnoea, Electrocardiogram abnormal, Fatigue, Headache, Nausea, Pneumonia, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Taste and smell disorders (narrow), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Diabetes, HTN, Cardiovascular disease
Allergies: Unknown
Diagnostic Lab Data: Abnormal CXR - diagnosis of pneumonia Abnormal EKG - unknown etiology
CDC Split Type:

Write-up: Death - Symptom onset date 04/24/21 to include chills, loss of taste/smell, headache, fatigue, cough, SOB, nausea, vomiting and diarrhea.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1549226

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