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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1038253

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Case Details

VAERS ID: 1038253 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died the next day; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and died the next day. The patient''s medical history was not provided. Concomitant medication use was not provided by the reporter. On 12 Jan 2021, approximately one day prior to the event, the patient received one of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 13 Jan 2021 the patient died. No additional information was provided in regards to the event. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 13 Jan 2021. The cause of death was unknown.; Reporter''s Comments: This case concerns a male patient of unknown age. The medical history and concomitant medication were not provided. The patient died approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


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