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

This is VAERS ID 1010114

Government Disclaimer on use of this data

Case Details

VAERS ID:	1010114 (history)
Form:	Version 2.0
Age:	58.0
Sex:	Male
Location:	Guam

Vaccinated:	2021-01-28
Onset:	2021-02-03
Days after vaccination:	6
Submitted:	0000-00-00
Entered:	2021-02-07

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	011L20A / 1	RA / IM

Administered by: Private Purchased by: ?
Symptoms: Death, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-03
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC Split Type:

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1010114