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From the 1/22/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 959001

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Case Details

VAERS ID: 959001 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-15
Onset:2021-01-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Nausea, Pulse absent, Resuscitation, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.


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