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From the 5/14/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1020227



Case Details

VAERS ID: 1020227 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-02-05
Onset:2021-02-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Illness, Patient isolation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: ALENDRONATE SODIUM 70MG TABLET (4''S) TAKE ONE (1) TABLET ACTIVE BY MOUTH ONE TIME EACH WEEK WITH WATER 30 MINUTES BEFORE EATING OR TAKING OTHER MEDICATIONS CALCIUM W/ VITAMIN D 600/500 SLOW RELEASE TAKE 2 TABLETS ACTIVE BY MOUT
Current Illness: Pt had COVID with symptom onset 1/27/21, pos test 1/28/21 admitted to Hosptial and was treated w/ remdesivir at , discharged 1/30 on Dexamethasone 6mg daily, no need for O2 supplement. First moderna COVID vaccine was 1/5/21.
Preexisting Conditions: 1)*AU SEVERE LOSS 2)Anemia - 3)Tubular adenoma of colon - 4)*SCLERAL PLAQUE EXCISION OS - STILL PO 2+ MONTH 5)Osteoarthritis - bilateral knees...worse in right knee -QUALIFIERS: Severity Moderate to severe 6)Chronic obstructive lung disease - 7)Onychomycosis - x10 -QUALIFIERS: Severity Mild to moderate Clinical course Chronic 8)Artificial lens present - OU 9)Hypermetropia - OD 10)Presbyopia - OU 11)Regular astigmatism - OD 12)Arcus of cornea - OU 13)Scarred macula - OS 14)Osteoporosis - 15)Osteoarthritis of knee - 16)Hypothyroidism - 17)Benign prostatic hyperplasia - 18)Hip pain, Right - Had right hip fracture pinning and has post traumatic DJD 19)Chronic pain - 20)Dry eyes - 21)Sensorineural hearing loss, Bilateral - 22)Nonexudative age-related macular degeneration, Bilateral -
Allergies: Allergies: CODEINE
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This is the patient who passed away 2d after his second COVID vaccine. Of note, the 2/8 telephone note makes it sound like he was hospitalized at time of death - that is incorrect. His daugther listed as EM contact works in the eye clinic here. He had mild illness, completed 10d isolation but missed his scheduled booster dose on 2/2 due to isolation. He was called on 2/5 when there was a booster visit cancellation and received his booster dose on that day. His daugther reported that he was doing fine and looking well on 2/7 AM, ate breakfast, shortly after stood up and just collapsed.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1020227

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