Report #2879208

Received Dec 22, 2025

Died

A note on interpretation. VAERS reports are unverified and may be incomplete or coincidental. A report does not establish that a vaccine caused an event, and counts should not be used to calculate incidence or infer causation. Full disclaimer

Overview

Sex: Male
Age: 77 yrs
State: IA
Recovered: Unknown
Vaccinated: Oct 13, 2025
Onset: Dec 22, 2025
Days to onset: 70
Hospital days: —

Vaccines (1)

Type	Name	Manufacturer	Dose	Lot	Route / Site
COVID19	COVID19 (COVID19 (MODERNA))	MODERNA	1	3052671	IM / RA

Symptoms (1)

Death

Symptom narrative

Resident passed away

Medical history

ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, PAROXYSMAL ATRIAL FIBRILLATION, CHRONIC KIDNEY DISEASE, UNSPECIFIED, HEART FAILURE, MALIGNANT NEOPLASM OF LEFT KIDNEY, EXCEPT RENAL PELVIS, ESSENTIAL (PRIMARY) HYPERTENSION, TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, ADJUSTMENT DISORDER WITH DEPRESSED MOOD,

Other medications

Atorvastatin, Prazosin, Eliquis, Lactobacillus, Magnesium, Ranolazine, Metformin, Acetaminophen, Tramadol, Isosorbide Mononitrate, Furosemide, Omega-3, Venlafaxine, Diclofenac Sodium, Pantoprazole, Amlodipine, Gabapentin, Vitamin D3, Hydral

Allergies

Methocarbamol, Jardiance