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From the 3/11/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1088180

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Case Details

VAERS ID: 1088180 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-03-05
Onset:2021-03-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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:
Current Illness: See Below
Preexisting Conditions: On Hospice due to: Chronic systolic (congestive) heart failure, Chronic kidney disease stage 3, Sick sinus syndrome, Unspecified atrial fibrillation, Presence of cardiac pacemaker, Muscle weakness, Alzheimer''s Disease
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to Hospice on 8/11/20. He experienced normal progression of his diseases until his death on 3/9/21.


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