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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 1081547

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Case Details

VAERS ID: 1081547 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-03-05
Onset:2021-03-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   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: LIQUID PROTEIN, PRILOSEC, LACTOBACILLUS, ELIQUIS
Current Illness: NONE
Preexisting Conditions: A-FIB, PERIPHERAL VASCULAR DISEASE, HERNIA REPAIR WITH BOWEL RESECTION JANUARY 2021
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: NO IMMEDIATE ADVERSE EVENTS PRESENT FOLLOWING IMMUNIZATION. RESIDENT WAS ALERT, RESPONSIVE, TALKATIVE, WITHOUT COMPLAINTS, AND ENGAGING IN NORMAL ACTIVITIES AFTER IMMUNIZATION, AS WELL AS THE FOLLOWING DAY. HE WAS FOUND IN BED THE SECOND MORNING AFTER VACCINATION (AT 6:25AM) WITHOUT VITAL SIGNS AND HAD EXPIRED PEACEFULLY IN HIS SLEEP. HE WAS A DNR, NO LIFE SUSTAINING MEASURES WERE PERFORMED.


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