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

This is VAERS ID 1080335



Case Details

VAERS ID: 1080335 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (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:
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: Anaphylaxis; A spontaneous report was received from a physician assistant concerning a patient of unspecified age and gender, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced anaphylaxis. The patient''s medical history was not provided. 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 (Lot number: unknown) for prophylaxis of COVID-19 infection. On an unknown date, after receiving vaccine, the patient died due to anaphylaxis. No further details were available at the time of this report. Treatment for the event was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event anaphylaxis was fatal .The patient died on an unspecified due to anaphylaxis. Autopsy details were not provided.; Reporter''s Comments: Very limited information regarding the event of anaphylaxis has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Anaphylaxis


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