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

This is VAERS ID 1217813



Case Details

VAERS ID: 1217813 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-13
Onset:2021-04-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   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
Current Illness: unknown; not currently ill per screening form
Preexisting Conditions: unknown
Allergies: none reported per screening form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: deceased on 4/13/21


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