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

This is VAERS ID 978567



Case Details

VAERS ID: 978567 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-12
Onset:2021-01-24
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Metformin 500mg PO BID for DM Phenobarbital 97.2mg QD for Seizure Dilantin 100mg, 2 caps, QHS for Seizure Eliquis 5mg BID for DVT Lipitor 10mg QHS for Hyperlipidemia
Current Illness: None
Preexisting Conditions: DM2, Seizure, HTN, Hyperlipidemia, PVD, History of CVA, Contractures of both knees, Dysphagia.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received the first dose of Moderna Vaccine on 01/12/2021 and Tested for COVID-19 on 01/12/2021. Resident tested positive on 01/13/2021. Resident was transferred to acute hospital on 01/19/2021 due to desaturation. Resident expired at Hospital on 01/24/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=978567

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