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

This is VAERS ID 1052700

Case Details

VAERS ID: 1052700 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Tennessee  
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: Unknown
Current Illness: COPD, Essential hypertension
Preexisting Conditions: COPD, Essential hypertension
Allergies: Aspirin, Bee Stings, Bupropion
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71 year old male patient recived the Moderna vaccine on 12/28/2020 and 1/27/2021. Tested positive for Covd-19 on 2/1/2021 (aysmptomatic). Passed away on 2/23/2021. Report came from facility.

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