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From the 6/11/2021 release of VAERS data:

This is VAERS ID 992571



Case Details

VAERS ID: 992571 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: He stated he was experiencing some shortness of breath with cold and walking up the steps. The patient did report that they had some bloody stool early in the week but that had resolved.
Preexisting Conditions: PMH: DM, HTN, Obesity, hyperlipidemia, Chronic kidney Disease, polyp?s removal. History of Angioedema secondary Ace Inhibitor
Allergies: ACE inhibitor
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient''s wife called the physician''s office with increasing SOB. MD advised that the patient go to the ED. While dressing, the patient became unresponsive, 911 called. Patient expired in ED.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=992571


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