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From the 3/11/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 1082850

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Case Details

VAERS ID: 1082850 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram spine, Electrocardiogram, Laboratory test, Mobility decreased, Nausea, Vomiting, X-ray limb
SMQs:, Acute pancreatitis (broad), Parkinson-like events (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, atorvastatin, Cymbalta, lyrica, finastride, hydrochlorathiazide iron, losartan, metoprolol tamsulosin, ambien
Current Illness: none
Preexisting Conditions: psoriasis (lips), neuropathy, HTN, anxiety/depression, type 2 DM
Allergies: Penicillin, sulfa
Diagnostic Lab Data: labs, EKG, CT abd, Ct c spine, shoulder xray, CT of Head
CDC Split Type:

Write-up: pt became nauseated and vomiting 1 day after getting vaccine, reported on Mon 2/22/21 but states was getting better, received call from sister on 2/25/21 that pt could not get out of bed on own - was sent to ER at that time


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210311&IDNUMBER=1082850


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