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From the 10/15/2021 release of VAERS data:

This is VAERS ID 937127



Case Details

VAERS ID: 937127 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Mirtazapine, Fentanyl Patch,
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had positive cases of COVID when we were able to begin vaccinating residents. Within about a week of vaccination, patient was tested positive for COVID. He was 91 years old and his immune system did not have the time to allow the vaccine to begin working before exposure. His age was a major contributing factor to his death.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=937127

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