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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 969219

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Case Details

VAERS ID: 969219 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: South Carolina  
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg
Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues
Preexisting Conditions: hypertensin gout
Allergies: no known allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon

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