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From the 1/14/2022 release of VAERS data:

This is VAERS ID 979081

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Case Details

VAERS ID: 979081 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-21
Onset:2021-01-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix
Current Illness: None
Preexisting Conditions: Acute systolic congestive heart failure, Atrial Fibrillation, Coronary Artery Disease, Left Ventricular Hypertrophy, Arteriosclerotic Heart Disease, Carotid Artery Stenosis, Ischemic Cardiomyopathy, Hypertension, Osteoarthritis, Myelodysplasia, COPD, Dyslipidemia, Malignant Neoplasm of Colon, Anemia
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.


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