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

This is VAERS ID 1764092

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Case Details

VAERS ID: 1764092 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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.MOD20213

Write-up: 1 person died after regular shots; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (1 person died after regular shots) in a patient of an unknown age and gender 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 an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were provided by the reporter. No treatment information details was provided by the reporter. It was reported that one person died after regular shots and reporter thinks it was moderna vaccine but was not sure about it. This case concerns a patient of unknown age and gender with no relevant medical history, who experienced the expected fatal event of Death, with no cause of death provided. The event occurred at an unknown date after a dose of Spikevax (unknown dose). The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Spikevax is not affected by this report. This case was linked to MOD-2021-332581 (Patient Link).; Sender''s Comments: This case concerns a patient of unknown age and gender with no relevant medical history, who experienced the expected fatal event of Death, with no cause of death provided. The event occurred at an unknown date after a dose of Spikevax (unknown dose). The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Spikevax is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


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