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

This is VAERS ID 1273409

Case Details

VAERS ID: 1273409 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: West Virginia  
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   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: Lasix, Coumadin, Lantus, Magnesium Oxide, Combivent Respimat Aerosol, fluoxetine, gabapentin, flomax, toprol, lisinopril, PreserVision AREDS, metformin, atorvastatin calcium, amlodipine, amiodarone, novolog, humalog, and levothyroxine.
Current Illness: UTI
Preexisting Conditions: Hypertension with heart failure, Benign prostatic hyperplasia, diabetes, atrial fibrillation, chronic pulmonary edema, obesity,
Allergies: Pollen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident CTB

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