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From the 4/30/2021 release of VAERS data:

This is VAERS ID 990780



Case Details

VAERS ID: 990780 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-28
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Marko Cell Carcinoma Matasisized
Preexisting Conditions: was in hospice since 8/11/20 had cancer
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=990780


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