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From the 3/5/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1057547

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Case Details

VAERS ID: 1057547 (history)  
Form: Version 2.0  
Sex: Male  
Location: Texas  
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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.)
Diagnostic Lab Data:

Write-up: 86 year old manager received the two doses of the Moderna vaccine and died; A spontaneous report was received from a consumer, concerning an 86-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unspecified date, the patient received their doses of mRNA-1273 (Lot number: unknown) through an unknown route in an unknown arm for prophylaxis of COVID-19 infection. On an unspecified date, it was reported that the patient passed away after receiving both doses. The cause of death was unknown. It was unknown if an autopsy was performed. The patient received both scheduled doses of mRNA-1273 prior to the event; therefore, action taken with the drug in response to the events is not applicable. The outcome of event "86 year old manager received the two doses of the Moderna vaccine and died" was fatal.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. No autopsy report provided. Further information has been requested.; Reported Cause(s) of Death: 86 year old manager received the two doses of the Moderna vaccine and died

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