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

This is VAERS ID 1254028



Case Details

VAERS ID: 1254028 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Hypotension, Thrombosis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATXINC.MOD2021083

Write-up: Patient passed away; patient had blood clots in his brain/ Legs/ Lungs/ Arms; Severe hypotension; This spontaneous case was reported by a physician (subsequently medically confirmed) and describes the occurrence of DEATH (Patient passed away), THROMBOSIS (patient had blood clots in his brain/ Legs/ Lungs/ Arms) and HYPOTENSION (Severe hypotension) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced DEATH (Patient passed away) (seriousness criterion death), THROMBOSIS (patient had blood clots in his brain/ Legs/ Lungs/ Arms) (seriousness criterion death) and HYPOTENSION (Severe hypotension) (seriousness criterion death). The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Treatment information was not provided. Company comment: This case concerns the death of a patient of unknown age and gender after administration of mrna-1273 ()LOT UNKNOWN). Very limited information regarding this event/s has been provided at this time. Further information has been requested. Critical details such as the mRNA-1273 date of administration, onset of any signs an d symptoms, and date of death is lacking.; Sender''s Comments: This case concerns the death of a patient of unknown age and gender after administration of mrna-1273 ()LOT UNKNOWN) . Very limited information regarding this event/s has been provided at this time. Further information has been requested. Critical details such as the mRNA-1273 date of administration, onset of any signs an d symptoms, and date of death is lacking.; Reported Cause(s) of Death: Unknown cause of death


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