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From the 5/7/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1052809

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Case Details

VAERS ID: 1052809 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Private       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: Neurontin, Proscar, Glucophage XR, Norvasc, Glucotrol, Lasix, Lipitor, Cozaar, Hygroton, Protonix, Hytrin
Current Illness: Pressure ulcers
Preexisting Conditions: BPF, CAD, Essential HTN, Diverticulosis of colon, Hyperlipidemia, Osteoarthritis, chronic respiratory failure, DM2 with peripheral vascular disease, peripheral edema, GERD, obstructive sleep apnea, osteoarthritis of knees,
Allergies: Lisinopril
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=1052809


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