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

This is VAERS ID 992342



Case Details

VAERS ID: 992342 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Dyspnoea, Hypertension, Oxygen saturation decreased, Pneumonia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Baby Aspirin
Current Illness: none
Preexisting Conditions: Diabetes Type 2
Allergies: NKDA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Shortness of Breath, decreased oxygen saturation, irregular heart rhythm, hypertension, Positive for COVID, bilateral pneumonia


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=992342

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