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

This is VAERS ID 987029



Case Details

VAERS ID: 987029 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: Pepcid Aspirin Finasteride Stress Plus Zinc Tab Seroquel Pravastatin Sodium Amlodipine besylate Flomax
Current Illness: PRESSURE ULCER OF RIGHT HEEL, STAGE 2 ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF OTHER PART OF FOOT ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF HEEL AND MIDFOOT
Preexisting Conditions: TRAUMATIC SUBDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, SUBSEQUENT ENCOUNTER MUSCLE WEAKNESS (GENERALIZED) UNSPECIFIED LACK OF COORDINATION FEEDING DIFFICULTIES OTHER REDUCED MOBILITY NEED FOR ASSISTANCE WITH PERSONAL CARE DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED DYSPHAGIA, OROPHARYNGEAL PHASE OTHER SYMBOLIC DYSFUNCTIONS ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ORTHOSTATIC HYPOTENSION HYPERLIPIDEMIA, UNSPECIFIED DEMENTIA WITH LEWY BODIES CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE HYPOKALEMIA PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE CONSTIPATION, UNSPECIFIED BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS ESSENTIAL (PRIMARY) HYPERTENSION REPEATED FALLS RETENTION OF URINE, UNSPECIFIED PRESENCE OF AORTOCORONARY BYPASS GRAFT PARKINSON''S DISEASE LOCALIZED SWELLING, MASS AND LUMP, RIGHT UPPER LIMB
Allergies: Penicillins Green Food Dye Dust Mites Aricept Namenda
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away at 8:15 am on 1/28/21-found to be without pulse/respirations/DNR order in place.


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