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From the 7/23/2021 release of VAERS data:

This is VAERS ID 977426



Case Details

VAERS ID: 977426 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-20
Onset:2021-01-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Seizure, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, Dexamethasone, Pantoprazole, Dilatin, Plaxis, Aspirin, VImpat, Keppra, Clopidogrel
Current Illness: 1. Melanoma with brain metastasis 2. Seizure disorder
Preexisting Conditions: 1. Melanoma with brain metastasis 2. Seizure disorder
Allergies: None
Diagnostic Lab Data: None. He was under hospice care.
CDC Split Type:

Write-up: Patient has a history of advanced melanoma with brain metastasis. He developed seizure disorder as well and had some mild seizures at home over the prior month. He received the vaccine at 4pm and was monitored in the office for 15 minutes. He then went home with his daughter whom he lives with. He ate dinner with her and read until 8pm when he went to his room. She found him in his room at 9pm unresponsive with seizures. Hospice was alerted and recommend oral valium. He continued to be unresponsive and expired the following day at 7:30 pm.


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