From the 10/15/2021 release of VAERS data:

This is VAERS ID 933578

Case Details

VAERS ID:	933578 (history)
Form:	Version 2.0
Age:	43.0
Sex:	Male
Location:	New York

Vaccinated:	2021-01-08
Onset:	0000-00-00
Submitted:	0000-00-00
Entered:	2021-01-11

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	012L20A / 1	LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=933578

From the 10/15/2021 release of VAERS data:

This is VAERS ID 933578

New Search

Government Disclaimer on use of this data