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

This is VAERS ID 1229797

Case Details

VAERS ID: 1229797 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Georgia  
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Had pneumonia in Feb 2021. Lives at a LTCF that developed an outbreak just after his first vaccination. Patient contracted COVID after his first Moderna vaccine and passed away on 4/16/2021.
Preexisting Conditions: sendss reports cardiovascular and renal disease
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Paient was vaccinated on 3/29/2021 with dose 1 of Moderna. Patient developed COVID symptoms on 4/4/2021 and passed away on 4/16/2021.

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