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

This is VAERS ID 1073471



Case Details

VAERS ID: 1073471 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 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: Hospice care
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Was found deceased a little less than 12 hours following COVID vaccination; A spontaneous report was received from a reporter concerning a 96-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and was found deceased a little less than 12 hours following COVID vaccination. The patient''s medical history included hospice care. No relevant concomitant medications were reported. On an unknown date, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, the patient was found deceased a little less than 12 hours following COVID vaccination, and he had had some changes over the last two days. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. On an unknown date the patient died. The cause of death was unknown. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 96 year old male patient, who was on hospice care experienced a fatal event of death, after receiving mRNA- 1273 (Lot# Unknown). Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


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