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

This is VAERS ID 1761641

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Case Details

VAERS ID: 1761641 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-12
Onset:2021-09-17
   Days after vaccination:217
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   Days after onset: 12
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: Covid antigen test on 9/17/21 for admission and sx
CDC Split Type:

Write-up: pt was admitted on 9/17/21 with increased shortness of breath, pt was a DNR/DNI at time of hospitaliztion, pt was made hospice on 9/29/21 pt expired 9/29/21


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