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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1583272

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Case Details

VAERS ID: 1583272 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-07-07
Onset:2021-07-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-08-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Influenza like illness, Myalgia, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPEI202100133881

Write-up: Flu-like illness; Myalgia; Pyrexia; This case was received via the Regulatory Authority (Reference number: 202100133881) on 04-Aug-2021 and was forwarded to Moderna on 04-Aug-2021. This regulatory authority case was reported by a physician and describes the occurrence of INFLUENZA LIKE ILLNESS (Flu-like illness), MYALGIA (Myalgia) and PYREXIA (Pyrexia) in a 51-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. No Medical History information was reported. On 07-Jul-2021, the patient received dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. On 08-Jul-2021, the patient experienced INFLUENZA LIKE ILLNESS (Flu-like illness) (seriousness criterion death), MYALGIA (Myalgia) (seriousness criterion death) and PYREXIA (Pyrexia) (seriousness criterion death). The patient died on 10-Jul-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown), the reporter did not provide any causality assessments. Concomitant product was not provided by the reporter. Treatment product was not provided by the reporter. This case concerns 51 year-old male patient who experienced the fatal events of myalgia, pyrexia and influenza like illness and died 3 days after receiving the dose of the mRNA-1273 vaccine. Cause of death was not specified. Very limited information has been provided at this time.; Sender''s Comments: This case concerns 51 year-old male patient who experienced the fatal events of myalgia, pyrexia and influenza like illness and died 3 days after receiving the dose of the mRNA-1273 vaccine. Cause of death was not specified. Very limited information has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


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