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

This is VAERS ID 1578038



Case Details

VAERS ID: 1578038 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-18
Onset:2021-07-18
   Days after vaccination:150
Submitted: 0000-00-00
Entered: 2021-08-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Malaise
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-09
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 23 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sxs onset 7/17. Moderna-1/21 and 2/18. Admitted to hospital 7/18 to 8/09. Died on 08/09 due to COVID related death per Disease report. Never admitted to ICU. Was in Step Down unit when he passed away


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