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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1002840



Case Details

VAERS ID: 1002840 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1002840

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