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From the 11/12/2021 release of VAERS data:

This is VAERS ID 1243053

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Case Details

VAERS ID: 1243053 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-16
Onset:2021-04-19
   Days after vaccination:62
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized x 2 and died within 60 days of receiving a COVID vaccine


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