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From the 4/30/2021 release of VAERS data:

This is VAERS ID 789121

Case Details

VAERS ID: 789121 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Oregon  
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2018-11-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2018-11-27
   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: Albuterol; alprazolam; aspirin; atenolol; atorvastatin; bisoprolol; cholecalciferol; ciclopirox; duloxetine; empagliflozin; fenofibrate micronized; fish oil; fluoxetine; glimepiride; HUMILIN R; hydrocodone-acetaminophen; lamotrigine; Lisino
Current Illness: no known acute illness
Preexisting Conditions: Hypertension; tobacco abuse; gouty nephropathy; chondromalacia patella; chronic pain (multiple sites); morbid obesity; hypercholesterolemia; chronic pancreatitis; alcohol dependence remission; insomnia; diabetic periopheral neuropathy; cardiomegaly 30% risk CAD; hypertriglyceridemia; anxiety disorder; coronary artery disease; dysphagia; sleep apnea; diabetes type 2 with complications
Allergies: Buproprion, escitalopram oxalate, mirtazapine
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient deceased on 11/27/18. At time of this report, reason of death is unknown, per reporting guidelines from CDC this report is being submitted by administering facility as immunization was given approximately one month prior to death of patient. No known adverse event was reported by patient or other family member directly related to vaccine administration.

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