From the 4/26/2024 release of VAERS data:

This is VAERS ID 1349910

Government Disclaimer on use of this data

Case Details

VAERS ID:	1349910 (history)
Form:	Version 1.0
Age:	85.0
Sex:	Male
Location:	Kansas

Vaccinated:	2021-01-07
Onset:	2021-01-07
Days after vaccination:	0
Submitted:	2021-01-08
Days after onset:	1
Entered:	2021-01-14
Days after submission:	6

Vaccination / Manufacturer	Lot / Dose	Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	039K20A / 2	LA / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA	039K20A / 2	LA / -

Administered by: Other Purchased by: Other
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Symptoms: & Death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1349910