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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1428705

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Case Details

VAERS ID: 1428705 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-05-01
Onset:2021-05-08
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001939 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure measurement, Heart rate, Heart rate increased, Hemiparesis, Hypertension, Vaccination failure
SMQs:, Lack of efficacy/effect (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Hypertension (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-21
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Hypertension; Joint pain
Allergies:
Diagnostic Lab Data: Test Date: 20210508; Test Name: Blood pressure; Result Unstructured Data: Increased; Test Date: 20210508; Test Name: Pulse rate; Result Unstructured Data: Rapid pulse
CDC Split Type: HUMODERNATX, INC.MOD20212

Write-up: (209/120 Hgmm); (115/min); This regulatory authority case was reported by a physician and describes the occurrence of HEMIPARESIS (hemiparesis), HYPERTENSION (209/120 Hgmm), HEART RATE INCREASED (115/min) and VACCINATION FAILURE in a 66-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001939) for COVID-19 vaccination. The patient''s past medical history included Hypertension and Joint pain. On 01-May-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) .5 milliliter. On 08-May-2021, the patient experienced HEMIPARESIS (hemiparesis) (seriousness criteria death, hospitalization and medically significant), HYPERTENSION (209/120 Hgmm) (seriousness criteria death and hospitalization) and HEART RATE INCREASED (115/min) (seriousness criteria death and hospitalization). On 21-May-2021, the patient experienced VACCINATION FAILURE (seriousness criteria death and hospitalization). The patient died on 21-May-2021. The cause of death was not reported. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 08-May-2021, Blood pressure measurement: 209/120 mmhg (High) Increased. On 08-May-2021, Heart rate: 115 (High) Rapid pulse. mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosing remained unchanged. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No concomitant medications reported. No treatment details provided. This fatal case concerns a 66-year-old male with serious unexpected events of hemiparesis, hypertension, heart rate increased, and vaccination failure. Event latency 8 days after first dose mRNA-1273. Outcome death. Based on current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Sender''s Comments: This fatal case concerns a 66-year-old male with serious unexpected events of hemiparesis, hypertension, heart rate increased, and vaccination failure. Event latency 8 days after first dose mRNA-1273. Outcome death. Based on current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Unknown cause of death


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