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From the 4/30/2021 release of VAERS data:

This is VAERS ID 986857



Case Details

VAERS ID: 986857 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Texas  
Vaccinated:2020-12-28
Onset:2020-12-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Mental status changes, Nausea
SMQs:, Acute pancreatitis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=986857


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