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

This is VAERS ID 1366907



Case Details

VAERS ID: 1366907 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-05-23
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-23
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20211

Write-up: Died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Died) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 23-May-2021 The patient died on 23-May-2021. The cause of death was not reported. It is unknown if an autopsy was performed. The reporter mentioned that grandma got Moderna vaccine and died yesterday (23 -May-2021) Concomitant medication and treatment information were not reported. Action taken with mRNA-1273 in response to the event was Not Applicable Company comment Very limited information regarding this event/s has been provided at this time. Further information has not been requested since follow up was denied. Reporter did not allow further contact; Sender''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has not been requested since follow up was denied.; Reported Cause(s) of Death: Unknown cause of death


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