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

This is VAERS ID 1466361

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Case Details

VAERS ID: 1466361 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-03-30
Onset:2021-05-28
   Days after vaccination:59
Submitted: 0000-00-00
Entered: 2021-07-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3000496 / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-28
   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: ASPIRIN CARDIO; PERINDOPRIL; AMIODARONE
Current Illness: Coronary disease (Date of diagnosis of stable coronary artery disease was unknown); Hypertension (Diagnosis date was unknown)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: CHMODERNATX, INC.MOD20212

Write-up: Patient; This regulatory authority case was reported by a physician and describes the occurrence of DEATH (Patient .) in an 81-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch nos. 3001656 and 3000496) for COVID-19 vaccination. Concurrent medical conditions included Hypertension (Diagnosis date was unknown) and Coronary disease (Date of diagnosis of stable coronary artery disease was unknown). Concomitant products included ACETYLSALICYLIC ACID (ASPIRIN CARDIO), PERINDOPRIL and AMIODARONE for an unknown indication. On 30-Mar-2021, the patient received first dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 27-Apr-2021, received second dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. Death occurred on 28-May-2021 The patient died on 28-May-2021. The cause of death was not reported. An autopsy was not performed. For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter considered DEATH (Patient.) to be unlikely related. The reporter stated that it was unknown whether the patient had any sort of allergy. On 28 May 2021 the patient collapsed in his backyard and was found dead by his wife. The face turned blue and was given futile cardiopulmonary resuscitation. The reporter assumed that the death may be due to sudden cardiac death or pulmonary embolism. No further treatment information was provided. Company comment: Very limited information regarding this event has been provided at this time. No follow up is possible. Most recent FOLLOW-UP information incorporated above includes: On 01-Jul-2021: Translation document was received on 07 Jul 2021. Patients medical history information and narrative was updated.; Sender''s Comments: Company comment: Very limited information regarding this event has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: Unknown cause of death


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