Adverse Event Reporting

VAERS ID 923993
Gender Male
Age 62
StateCode NC
Pharmaceutical Company MODERNA
Lot Number 039K20A
Number of vaccinations 1
Vaccinated 2020-12-30
Onset 2021-01-02
Condition Died
  • Death

Current Illness


Preexisting Conditions

History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma

Other Medications


Previous Vaccinations


Hay fever

Laboratory Data


Patient was vaccinated Dec 30, 2020.
Prime dose of Moderna vaccine.
Observed for full 15 minutes post-injection.
No complaints when asked during observation.
Subsequently, vaccine clinic staff learned from the patient's supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021.
By report from the supervisor, the patient was found dead at his home.
The patient's primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021).
Electronic Medical Record without any information since the vaccination.