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From the 11/19/2021 release of VAERS data:

This is VAERS ID 962318

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Case Details

VAERS ID: 962318 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-29
Onset:2021-01-19
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Called to schedule second vaccine and daughter reports that he died on01/19/2021 with "COVID"


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