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

This is VAERS ID 1236426



Case Details

VAERS ID: 1236426 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-03-20
Onset:2021-03-27
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Prostatic neoplasm NOS
Preexisting Conditions: Medical History/Concurrent Conditions: Aneurysm aortic; Aortic surgery; Comments: Npl. prostatae, St.p. Bauchaortenaneurysma -Op 2018
Allergies:
Diagnostic Lab Data:
CDC Split Type: ATMODERNATX, INC.MOD20210

Write-up: (Moderna) am 20.03.2021; This regulatory authority case was reported by a physician and describes the occurrence of PULMONARY EMBOLISM ((Moderna) am 20.03.2021) in a 57-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Npl. prostatae, St.p. Bauchaortenaneurysma -Op 2018. The patient''s past medical history included Aneurysm aortic in 2018 and Aortic surgery in 2018. Concurrent medical conditions included Prostatic neoplasm NOS. On 20-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 27-Mar-2021, the patient experienced PULMONARY EMBOLISM ((Moderna) am 20.03.2021) (seriousness criterion death). The patient died on 29-Mar-2021. The reported cause of death was Pulmonary embolism. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. No concomitant medications were reported. The treatment information included reanimation on 29 Mar 2021. Action taken with mRNA-1273 in response to the events was not applicable.; Sender''s Comments: This is a case of death in a 57-year-old male subject with a medical history of AAA, Ca Pancreas, who died 9 days after receiving the first dose of vaccine. Based on information received, death was due to pulmonary embolism, which is assessed as unlikely related to mRNA-1273.; Reported Cause(s) of Death: Pulmonary embolism


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