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

This is VAERS ID 1117316



Case Details

VAERS ID: 1117316 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-18
Onset:2021-03-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   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: Unknown - Patient has never filled prescriptions
Current Illness: Unknown
Preexisting Conditions: Unknown - Patient did not see a health provider in the past year
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Sister in law called on 3-19-2021 to report that had died a day after receiving his Moderna vaccine. She stated he was found in his driveway and was unable to be resuscitated after being rushed to the hospital.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1117316


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