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

This is VAERS ID 1221176



Case Details

VAERS ID: 1221176 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Unknown  
Location: Oregon  
Vaccinated:2021-03-30
Onset:2021-04-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (he died) in a 49-year-old patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No reported medical history). On 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on 03-Apr-2021 The patient died on 03-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were reported. No treatment medications were reported. Action taken with mRNA-1273 in response to the event was not applicable. Very limited information regarding this event has been provided at this time. Further information has been requested; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1221176

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