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

This is VAERS ID 1157293



Case Details

VAERS ID: 1157293 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-23
Onset:2021-02-22
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042460 / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Condrosulf; COVERAM; INVOKANA [CANAGLIFLOZIN]; JANUMET; PLAVIX
Current Illness: Arterial hypertension; Lumbo-sacral pain; Obesity; Type 2 diabetes mellitus
Preexisting Conditions: Medical History/Concurrent Conditions: Arterial stent insertion (mesenteric artery and celiac trunk); Mesenteric ischemia; Percutaneous coronary intervention (mesenteric artery and celiac trunk)
Allergies:
Diagnostic Lab Data:
CDC Split Type: CHMODERNATX, INC.MOD20210

Write-up: Death; A regulatory report, was received from a physician concerning a 76-year-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced death. The patient''s medical history included type 2 diabetes mellitus, arterial hypertension, obesity, mesenteric ischemia, lumbovertebral syndrome, and PTCA and stenting of the mesenteric artery and celiac trunk. Concomitant medications included chondroitin sulfate sodium, amlodipine besilate/perindopril arginine, canagliflozin, metformin hydrochloride/sitagliptin phosphate, and clopidogrel bisulfate. On 23 JAN 2021, the patient received their first of two planned doses of mRNA-1273 (Batch: 300042460) intramuscularly in left arm for prophylaxis of COVID-19 infection. On 20 FEB 2021, the patient received their second of two planned doses of mRNA-1273 (Batch: 300042723) intramuscularly in left arm for prophylaxis of COVID-19 infection. On 22 FEB 2021, the patient died. Cause of death was unknown. Plans for an autopsy was not provided. The action taken with mRNA-1273 in response to the event was not applicable. The reporter considered the death unlikely related to mRNA-1273.; Reporter''s Comments: This case concerns a 76-year-old, male, with multiple comorbidities, who experienced a serious (fatal) unexpected event of death (unknown cause). Death occurred 2 days after receiving 2nd dose of mRNA-1273 (Lot# 300042723). Based on the current available information, the event was considered unrelated to the study medication in agreement with the reporter''s assessment. The advance age and multiple co-morbidities may remain as risk factors. No further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


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