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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 1035866

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Case Details

VAERS ID: 1035866 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-11
Onset:2021-02-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: DOXAZOSIN TAB,ORAL 2MG TAKE TWO TABLETS BY MOUTH TWICE A DAY FOR BLOOD PRESSURE DABIGATRAN CAP,ORAL 150MG TAKE ONE CAPSULE BY MOUTH TWICE A DAY LABETALOL TAB 200MG T
Current Illness: None
Preexisting Conditions: Chronic atrial fibrillation [Chronic atrial fibrillation, unspecified] Hyperlipidemia [Hyperlipidemia, unspecified] Benign essential hypertension [Essential (primary) hypertension] GERD - Gastro-esophageal reflux disease [Gastro-esophageal reflux disease without esophagitis] Carcinoma of colon [Carcinoma in situ of colon] Rosacea [ROSACEA]
Allergies: Simvastatin Influenza
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt died on 2/15/21. On 2/13/21, pt complained of muscle aches.


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