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From the 4/1/2021 release of VAERS data:

This is VAERS ID 992154

Case Details

VAERS ID: 992154 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-11
Onset:2021-01-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: duo neb, lasix, protonix, prednisone, apap , dulcolax, cough syryp, levsin, MOM, morphine, tums, ativan, flomax, aquaiphor oint, senna, muscle rub
Current Illness: None
Preexisting Conditions: Alzheimers Dementia late onset without behavioral disturbance, Hypotension, benign prostatic hyperplasia, Left inguinal hernia found 2016, Left shoulder lesions, Hypothyroidism, GERD (gastroesophageal reflux disease), Mixed hyperlipidemia, Basal Cell Carcinoma, Kyphosis, Hx of shingles, dysphagia, Legally blind LEFT eye, cataracts both eyes, frality, hard of hearing Hospice- general decline in the past year.
Allergies: NKA
Diagnostic Lab Data: none, pt on hospice, comfort cares
CDC Split Type:

Write-up: No adverse events reported post vaccine. 1 st dose on 1/11/21 by public health. Death 1/31/21 Patient was on hospice for gradual decline.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=992154


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