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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1457004

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Case Details

VAERS ID: 1457004 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kansas  
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-07-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Dyspepsia, Feeling abnormal, Feeling hot
SMQs:, Dementia (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific dysfunction (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prostate cancer treatment for 2-3 years, other meds unknown
Current Illness:
Preexisting Conditions: prostate cancer in remission, diabetes since 1990, heart attack with stent placement in 1995. On oxygen nightly since 2008.
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received dose 2 of Moderna vaccine on 3/11/21. Symptoms worse after 2nd dose, and on March 31, 2021 get worse. On April 4 at church, became very hot and weaker and weaker. Came home and put him to bed and slept some. At lunch time, ate a bite of jello and sipped 7 up and said he did not feel very good. Took an Alka Seltzer for heart burn, but it did not help. Went to sleep. Wife unable to waken him later that day. Died 4/4/21.

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