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

This is VAERS ID 1368779

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Case Details

VAERS ID: 1368779 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-17
Onset:2021-05-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Abdominal distension, Abdominal pain upper, Death, Insomnia, Myalgia, Nausea
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-01
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Asthma
Allergies: None
Diagnostic Lab Data: Los Angeles County Coroner''s case 2021-06655
CDC Split Type:

Write-up: After receiving second dose of vaccine, complained of stomach pain and feeling "bloated." Later had muscle pain, insomnia, and nausea. Found dead at home on 6/1.


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