From the 12/27/2024 release of VAERS data:

This is VAERS ID 1006316

Government Disclaimer on use of this data

Case Details

VAERS ID:	1006316 (history)
Form:	Version 2.0
Age:	78.0
Sex:	Male
Location:	Georgia

Vaccinated:	2021-01-28
Onset:	2021-02-02
Days after vaccination:	5
Submitted:	0000-00-00
Entered:	2021-02-05

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	028L20A / 1	RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-02
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: see nursing home record
Current Illness: none
Preexisting Conditions: Trach; tube feeder; ileostomy; HTN; CAD; HLD; hypothyroidism; renal cell carcinoma; prostate cancer; Previously COVID positive but unkown date- it was before entering nursing home.
Allergies: none
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: death- 2/2/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1006316