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From the 2/18/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1029511

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Case Details

VAERS ID: 1029511 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol 500mg as needed Zyrtec 10mg daily Lysine 500mg daily Nyquil/Dayquil as needed Pepcid 20mg at bedtime
Current Illness: None
Preexisting Conditions: None, never sick
Allergies: None
Diagnostic Lab Data: Jan. 27 2021 when taken to the E.R
CDC Split Type:

Write-up: Developed severe shortness of breath.


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