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

This is VAERS ID 1027967



Case Details

VAERS ID: 1027967 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-15
Onset:2021-01-20
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Coagulopathy, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy


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