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From the 11/26/2021 release of VAERS data:

This is VAERS ID 966844

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Case Details

VAERS ID: 966844 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Feeling abnormal, Palpitations
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Cardiomyopathy (broad)

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: Unknown
Current Illness: DM II
Preexisting Conditions: DM II
Allergies: KNA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient is reported to have died at home, the day after his COVID test. Family member states that he did good the afternoon and evening after his COVID-19 injection, but that he started not feeling good the next day. The patient "was having palpitations". The family tried to convince him to go to the Emergency Room, but he refused. Patient died at home.


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