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

This is VAERS ID 996423



Case Details

VAERS ID: 996423 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-01-04
Onset:2021-01-10
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cerebrovascular accident, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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:
Current Illness:
Preexisting Conditions: Wife reported patient had diabetes and high blood pressure.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a CVA and passed away suddenly 1/10/21


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=996423

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