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

This is VAERS ID 1034985



Case Details

VAERS ID: 1034985 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Kentucky  
Vaccinated:2021-01-04
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: 4 Nurshing home patients Died; A Spontaneous report was received from a pharmacist concerning 4 nursing home patients of unspecified age and gender who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patients'' medical histories were not provided. No relevant concomitant medications were reported. On unspecified dates, 4 nursing home patients received their first of two planned doses of mRNA-1273 (Lot # 039K20A) for prophylaxis of COVID-19 infection. A pharmacist reported that they just learned 4 nursing home patients died after the first dose of the Modern vaccine. The patients were buried, and no autopsies were conducted. The pharmacist suspected latent Covid-19 on the patients and that the vaccine precipitated this outcome. No treatment information was provided. Action taken with the second dose of mRNA-1273 in response to the event was not applicable. The event 4 nursing home patients died was fatal.; Reporter''s Comments: This case concerns 4 nursing home patients of unspecified age and gender who received their first dose of Moderna''s COVID-19 vaccine (mRNA-1273)Lot # 039K20A) and died. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: died


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