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From the 1/14/2022 release of VAERS data:

This is VAERS ID 970930

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Case Details

VAERS ID: 970930 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-09
Onset:2021-01-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Fall, Head injury, Respiratory disorder, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: I-caps
Current Illness: -
Preexisting Conditions: AAA
Allergies: Penicillins
Diagnostic Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.
CDC Split Type:

Write-up: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.


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