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From the 4/30/2021 release of VAERS data:

This is VAERS ID 1094197



Case Details

VAERS ID: 1094197 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-26
Onset:2021-03-11
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ500AB / 1 LA / IM
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. T033663 / 1 LA / IM
VARZOS: ZOSTER (SHINGRIX) / GLAXOSMITHKLINE BIOLOGICALS ZJ432 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Feeling abnormal
SMQs:, Dementia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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: ELIQUIS, LASIX, PROTONIX,ALTACE, TRADJENTA, LUMIGAN, AMIODARONE, METOPROLOL
Current Illness: UNKNOWN
Preexisting Conditions: HBP, DIABETES, MAY BE OTHERS
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN - CONTACT PHYSICIAN OR HOSPITAL I AM NOT AWARE IF HE WAS TAKEN TO HOSPITAL OR DR''S OFFICE YESTERDAY OR NOT.
CDC Split Type:

Write-up: DEATH - PT''S WIFE CALLED 3-11 TO TELL US PATIENT WAS FEELING BAD, AND TO ASK WHAT TO DO. WE SENT A PULSEOXIMETER, AND ADVISED TO CONTACT DR. - ON MORNING OF 3-12, PT''S WIFE CALLED TO TELL US HE HAD PASSED AWAY DURING THE NIGHT.


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