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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1764856

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Case Details

VAERS ID: 1764856 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-14
Onset:2021-09-22
   Days after vaccination:251
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Metastatic Lung Cancer
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt died after contracting COVID-19 in early August 2021.


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