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From the 5/7/2021 release of VAERS data (an older release, current is 11/12/2021):

This is VAERS ID 1036993

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Case Details

VAERS ID: 1036993 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-16
Onset:2021-02-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Known Prescription Meds dispensed at pharmacy: Oxycodone/Acet Prn, Gabapentin, Metoprolol, Pantoprazole, Tamsulosin, Atorvastatin, Clopidogrel, Montelukast, Trazodone, Do not have info on OTC or Dietary supplements
Current Illness:
Preexisting Conditions: Hx of migraine headaches
Allergies: noted on admin form: Ibuprofen
Diagnostic Lab Data: Daughter said there was going to be an autopsy because there was no apparent cause
CDC Split Type:

Write-up: Patient reported at review of questionnaire had headache that day. Temp was taken, 97.8, okay. proceeded. Conversing customer friend in store afterward. When timer went off, said he was fine, he and his wife left. Daughter called to store Wednesday morning, said Pt had passed away Tuesday, that it was unknown the cause, and just wanted to let us know. We did not take down her phone number and last name. The patient was a long time customer.


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1036993


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