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From the 4/23/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1230868

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Case Details

VAERS ID: 1230868 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-01
Onset:2021-04-03
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 059A21A / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Death, Pain in extremity, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   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: Gabapentin 300mg, aspirin 81mg, losartan potassium 50mg, allopurinol 100mg, vitamin d2 1.25mg,finasteride 0.5mg , rosuvastatin calcium 5mg, torsemide 100mg, verapamil 240mg, tamsulosin 0.4mg
Current Illness: None
Preexisting Conditions: Hypertension, high cholesterol, chronic kidney disease because of DM, hypothyroidism, gout, neuropathy because of DM
Allergies: No allergies to medications or food
Diagnostic Lab Data: None
CDC Split Type: Moderna 059A21A

Write-up: My dad took vaccine 4/1 5pm, he had arm pain 4/2 morning, felt like fever in the afternoon. After 5pm, he compliant with joint pain. He was found on the floor dead 4/3 at 1am at home.


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