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

This is VAERS ID 1753284

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Case Details

VAERS ID: 1753284 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-17
Onset:2021-08-04
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-10-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-13
   Days after onset: 9
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:

Write-up: COVID infection. Specimen collected on 8/11/21. Patient died on 8/13/21.


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