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

This is VAERS ID 915880



Case Details

VAERS ID: 915880 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Montana  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died within 12 hours of receiving the vaccine.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=915880


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