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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1219667



Case Details

VAERS ID: 1219667 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-06
Onset:2021-04-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Computerised tomogram, Death, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Hydralazine, Furosemide, Warfarin, Potassium, Glipizide
Current Illness: none
Preexisting Conditions: Diabetic, Stage 4 Kidney Failure, Heart Disease, High Blood Pressure, Sleep Apnea.
Allergies: None
Diagnostic Lab Data: CT Scans
CDC Split Type:

Write-up: Patient had a Hemorrhagic stoke and passed away.


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