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

This is VAERS ID 1759418

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Case Details

VAERS ID: 1759418 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Michigan  
   Days after vaccination:225
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Intensive care, Positive airway pressure therapy, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
   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, lipitor, calcium carbonate, Zyrtec, temovate, vitamin B12, Avodart, Ferocon, Flonase, Neurontin, Zestril, Glucophage, Aleve, Saw Palmetto, Flomax, ultram, kenalog cream.
Current Illness:
Preexisting Conditions: Chronic back pain, HTN, DM2, extracranial carotid artery stenosis, arthritis, hyperlipidemia, B12 deficiency, cerebral thrombosis with cerebral infarction, vitiligo, obstructive pattern present on pulmonary function testing, aortic extasia (abdominal), monoclonal gammopathy of unknown significance, spinal stenosis, neuropathy, anemia, history of cerebrovascular accident, benign prostatic hyperplasia.
Allergies: "Seasonal allergies"
Diagnostic Lab Data: COVID positive swab on 09/19/21.
CDC Split Type:

Write-up: Fully COVID vaccinated patient who admitted through emergency department with COVID positive test on 09/19/21. Patients respiratory status continued to decline, he required CCU admission high flow oxygen, and subsquently BiPAP. Medical team reviewed ongoing respiratory decline and grave status with patient and family who declined intubation. Patient moved to comfort care and died on 10/02/21.

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