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From the 7/16/2021 release of VAERS data:

This is VAERS ID 950979



Case Details

VAERS ID: 950979 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Headache
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: allopurinol -Zyoprim 3000 mg amlodipine Norvasc 5 mg Lispro 100/unit /ml ups us to 150 unit daily per insulin scale Levemir U-100 - 100/unit/ml - (3ML) 55 units nightly Levothryoxine -Synthroid - 137 mcg - daily Simvastatin 25 mg - d
Current Illness:
Preexisting Conditions: IPF - Idoipathic Pulmonary Fibrosis Diabetic
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache after dose was given at 10:00 a.m Died at after 7:30 pm the same night the dose was given.


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