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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 940602

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Case Details

VAERS ID: 940602 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-08
Onset:2021-01-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K209 / 5 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Injection site pain, Myocardial infarction, Pain, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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: see attached
Current Illness: None reported
Preexisting Conditions: HTN, Type II DM, High cholesterol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 1/8/2021. On 1/9/2021 I checked on patient via phone for symptoms or problems and he reported none but mild soreness at injection site. On 1/10/2021 family friend called me to tell me that patient had expired at about 8:00 pm. Patient reportedly complained of "pain" unspecific and collapsed at home. Hospital reportedly told family that it appeared to be a "heart attack".


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