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From the 5/7/2021 release of VAERS data (an older release, current is 11/19/2021):

This is VAERS ID 1036437

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Case Details

VAERS ID: 1036437 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-26
Onset:2021-02-17
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: None reported
Preexisting Conditions: None reported
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is deceased. Family called the pharmacy on 2-17-21 to let us know he would not be coming for his second appointment. When the pharmacist tried to call the family back for more info, the phone number on file doesn''t work.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1036437


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