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

This is VAERS ID 1124383



Case Details

VAERS ID: 1124383 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-01-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC Split Type:

Write-up: DEATH Narrative: Events surrounding patient''s death are unknown- nothing is documented in medical record regarding event. Causality of death is unknown. This event is being reported due to the timing of the death in relation to the receipt of vaccine (4 days).


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124383

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