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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1027502



Case Details

VAERS ID: 1027502 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-14
Onset:2021-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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, Xanax, Albuterol, Flomax, Polyethylene glycol
Current Illness: N/A
Preexisting Conditions: COPD
Allergies: N/A
Diagnostic Lab Data: No tests were taken. No autopsy completed unless I paid them $5000
CDC Split Type:

Write-up: My dad received his first COVID vaccine on January 14, 2021. On January 16, 2021 he ate breakfast around 7:00 am and went back to his room. When the staff checked on him around 8:00 am they found my dad unresponsive. His blood pressure was over 220 and his pulse was 43. They began manual CPR until the paramedics arrived, but my dad died.


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