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

This is VAERS ID 967506

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Case Details

VAERS ID: 967506 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-16
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died within 5 days of receiving vaccine. Exact cause and day unknown.


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