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This is VAERS ID 1764194

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First Appeared on 10/8/2021

VAERS ID: 1764194
VAERS Form:2
Age:79.0
Sex:Male
Location:South Carolina
Vaccinated:2021-05-11
Onset:2021-07-20
Submitted:0000-00-00
Entered:2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Cerebrovascular accident, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-07-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20213

Write-up: Swelling and bumps; Double stroke; This spontaneous case was reported by a consumer and describes the occurrence of CEREBROVASCULAR ACCIDENT (Double stroke) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 11-May-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 20-Jul-2021, the patient experienced CEREBROVASCULAR ACCIDENT (Double stroke) (seriousness criteria death and medically significant). On an unknown date, the patient experienced SWELLING (Swelling and bumps). The patient died on 20-Jul-2021. The reported cause of death was double stroke. It is unknown if an autopsy was performed. At the time of death, SWELLING (Swelling and bumps) outcome was unknown. Patient passed away after getting Moderna COVID-19 Vaccine. No relevant concomitant medications were reported. No treatment information was reported.; Sender''s Comments: This case concerns a 75 year old male with no relevant medical history who experienced serious unexpected fatal event of CVA approximately 2 months after the first dose of the vaccine. Rechallenge was not applicable. The benefit-risk relationship is not affected by this report.; Reported Cause(s) of Death: Double Stroke

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