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

This is VAERS ID 1741085

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Case Details

VAERS ID: 1741085 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-03-06
Onset:2021-09-20
   Days after vaccination:198
Submitted: 0000-00-00
Entered: 2021-09-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 052E21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Death, Endotracheal intubation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Ulcerative colitis, Cellulitis of RLE CKD, Polycystic Kidney disease, Osteoarthritis, Hyperlipidemia, Post kidney transplant, Long term use of immunosuppressive drug, would of lower extremity, ESRD on dialysis, CVA, Immunosuppressed status,
Preexisting Conditions: Ulcerative colitis, Cellulitis of RLE CKD, Polycystic Kidney disease, Osteoarthritis, Hyperlipidemia, Post kidney transplant, Long term use of immunosuppressive drug, would of lower extremity, ESRD on dialysis, CVA, Immunosuppressed status,
Allergies: NKA
Diagnostic Lab Data: 9/21/2021 SARS CoV RAP RNA (RT RNA) positive 9/23/2021 SARS CoV RNA (RT RNA) positive 9/23/2021 SARS CoV PAN (RT RNA) positive
CDC Split Type:

Write-up: Developed Acute Respiratory Failure leading to intubation and death.


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