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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1418579

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Case Details

VAERS ID: 1418579 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-22
Onset:2021-05-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Ischaemic stroke, Pulmonary embolism
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-26
   Days after onset: 1
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: AFib; Chronic alcoholism; Pneumopathy; Tabaquism
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRMODERNATX, INC.MOD20212

Write-up: Embolism pulmonary; Ischemic stroke; This regulatory authority case was reported by a pharmacist and describes the occurrence of PULMONARY EMBOLISM (Embolism pulmonary) and ISCHAEMIC STROKE (Ischemic stroke) in a 54-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. Concurrent medical conditions included Chronic alcoholism, Tabaquism, Pneumopathy in 2020 and AFib. On 22-May-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) .5 milliliter. On 25-May-2021, the patient experienced PULMONARY EMBOLISM (Embolism pulmonary) (seriousness criteria death and medically significant) and ISCHAEMIC STROKE (Ischemic stroke) (seriousness criteria death and medically significant). The patient died on 26-May-2021. The reported cause of death was avc. An autopsy was performed, but no results were provided. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. The concomitant medications were not provided. The treatment information was not provided. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was not applicable. Company Comment: This is a case of death in a 54 -years-old male subject with no reported medical hx, who died on the 04 days after receiving first dose of vaccine. Very limited information has been provided at this time. No further information has been requested.; Sender''s Comments: This is a case of death in a 54 -years-old male subject with no reported medical hx, who died on the 04 days after receiving first dose of vaccine. Very limited information has been provided at this time. No further information has been requested.; Reported Cause(s) of Death: AVC


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