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From the 2/12/2021 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 1020724



Case Details

VAERS ID: 1020724 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-21
Onset:2021-02-02
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID19,
Preexisting Conditions: hypertension and Coronary Artery Disease
Allergies: codeine, penicillin
Diagnostic Lab Data: COVID19 Roche LIAT PCR test - Detected
CDC Split Type:

Write-up: Patient sent to the ED or sudden onset of shortness of breath on 02/02/2021. Per documentation by the MD, the patient had COVID19 "several weeks ago" and the nursing facility felt like he had recovered. A rapid test done in the ED was negative. When the patient worsened and seemed to be following the same path as other COVID patients, a send out PCR test was done, which was positive. The patient worsened and passed away that same day (02/05/2021) I was not made aware that the patient had the vaccine on 01/21/2021 until Monday 02/08/2021.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210212&IDNUMBER=1020724

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