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From the 10/8/2021 release of VAERS data:

This is VAERS ID 953348



Case Details

VAERS ID: 953348 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate
Current Illness:
Preexisting Conditions: Chronic pain, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was living in a nursing home with positive cases when administered. His age and chronic condition was such that he did not have time after the vaccination to avoid exposure or develop immunity.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=953348

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