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

This is VAERS ID 1036480

Case Details

VAERS ID: 1036480 (history)  
Form: Version 2.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Endotracheal intubation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: amlodipine, aspirin, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21

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