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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 923993

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Case Details

VAERS ID: 923993 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: North Carolina  
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Private       Purchased by: ?
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-02
   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: Unknown
Current Illness: No
Preexisting Conditions: History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma
Allergies: Hay fever
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated Dec 30, 2020. Prime dose of Moderna vaccine. Observed for full 15 minutes post-injection. No complaints when asked during observation. Released. Subsequently, vaccine clinic staff learned from the patient''s supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021. By report from the supervisor, the patient was found dead at his home. The patient''s primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021). Electronic Medical Record without any information since the vaccination.

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