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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1020079



Case Details

VAERS ID: 1020079 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-14
Onset:2021-01-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, General physical health deterioration, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Symbicort, sotalol, mexilitine, tiotropium, carbidopa/levodopa, aripiprazole, allopurinol, citalopram, insulin, pantoprazole, pravastatin, tamsulosin, tioptropium, warfarin, bumetanide, bupropion
Current Illness:
Preexisting Conditions: Ischemic Cardiomyopathy, Coronary Artery Disease (MI x2 1989 and 1995), VT (ablation 2009) with Boston Scientific ICD Sick Sinus Syndrome (PPM), Type 2 Diabetes, Chronic Kidney Disease, Hypertension, Hyperlipidemia Peripheral Vascular Disease, Parkinson''s Disease Antiphospholipid Antibody Syndrome Heparin Induced Thrombocytopenia
Allergies: Heparin Atorvastatin
Diagnostic Lab Data: Related to hospital stay. Unavailable currently.
CDC Split Type:

Write-up: Received Moderna covid vaccination 1/14/2021. 1/16/2021 received report of cough and difficulty breathing. Proceeded to hospital and was diagnosed Covid+ on testing. Continued to decline, died 1/31/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1020079

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