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

This is VAERS ID 1032321



Case Details

VAERS ID: 1032321 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-19
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021


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