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

This is VAERS ID 997297



Case Details

VAERS ID: 997297 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-04
Onset:2021-01-17
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chronic kidney disease, Death, Pneumonia, Septic shock, Urinary tract infection
SMQs:, Rhabdomyolysis/myopathy (broad), Toxic-septic shock conditions (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 1/17/21. Death certificate reports: Septic Shock, UTI, Pneumonia, Chronic Renal Failure


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