Report #2900105

Received Jun 15, 2026

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: 91 yrs
State: IA
Recovered: Unknown
Vaccinated: Apr 8, 2026
Onset: Jun 13, 2026
Days to onset: 66
Hospital days: —

Vaccines (1)

Type	Name	Manufacturer	Dose	Lot	Route / Site
COVID19	COVID19 (COVID19 (MODERNA))	MODERNA	1	3052786	IM / LA

Symptoms (1)

Death

Symptom narrative

resident passed away

Medical history

UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, HEART FAILURE, UNSPECIFIED, ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA], BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS, UNSPECIFIED GLAUCOMA

Other medications

Bacitracin ointment, Acetaminophen, Lisinopril, Hydralazine, Levothyroxine, Jardiance, Ipratropium- Albuterol solution, Advair diskus inhaler, Guaifenesin, Amlodipine, Tamsulosin, Sertraline, Senokot, Loratadine, Furosemide, Aspirin, Polye

Allergies

No known allergies