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From the 5/7/2021 release of VAERS data:

This is VAERS ID 900124



Case Details

VAERS ID: 900124 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-09-15
Onset:2020-09-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA4: INFLUENZA (SEASONAL) (FLUAD QUADRIVALENT) / SEQIRUS, INC. 279793 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Death, Feeling cold
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-09-17
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel 75mg once a day, Rosuvastatin 10mg once a day
Current Illness:
Preexisting Conditions:
Allergies: no allergies to medications
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient relayed to daughter that he was cold and was having chills. He stated he was going to take a shower. He passed away sometime after this and was found 2 days later per his daughter. Date of death was listed as 9/17/2020 on death certificate.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=900124


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