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

This is VAERS ID 1054699



Case Details

VAERS ID: 1054699 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1054699

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