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From the 11/26/2021 release of VAERS data:

This is VAERS ID 969699

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Case Details

VAERS ID: 969699 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-19
Onset:2021-01-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #027L20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide
Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker
Preexisting Conditions: Coronary heart disease
Allergies: None
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient died.


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