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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 1173602

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Case Details

VAERS ID: 1173602 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-23
Onset:2021-03-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: Passed away on the sleep; A spontaneous report was received from a pharmacist concerning a 73-years-old male patient who received Moderna''s COVID-19 vaccine and passed way on the sleep/death. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (lot number: 024M20A) on 23 Jan 2021. On 23 Mar 2021, patient received second of two planned doses of mRNA-1273 (lot number: 047A21A) intramuscularly for COVID-19 prophylaxis. On an unknown date in Mar 2021, the patient passed away on the sleep. The patient received both scheduled doses of mRNA-1273 prior to the event therefore, action taken with the drug in response to the event was not applicable. The patient died on the sleep on an unspecified date in Mar 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: This case concerns a 73-years-old, male patient, who died. The cause of death was unknown. Plans for an autopsy were unknown. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


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