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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1302844

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Case Details

VAERS ID: 1302844 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-05-06
Onset:2021-05-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026C21A / 2 - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Autopsy, Chest pain, Death, Dyspnoea, Lethargy
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-09
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydroxyzine pamoate
Current Illness:
Preexisting Conditions: Hypertension, non-insulin dependent diabetes
Allergies: None
Diagnostic Lab Data: Autopsy on May 10, 2021. Results pending.
CDC Split Type:

Write-up: Lethargy began the day of vaccine and shortness of breath along with abdominal and chest pain followed the next day. Decedent was found deceased the next evening.


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