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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1026443



Case Details

VAERS ID: 1026443 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-02-09
Onset:2021-02-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Pulseless electrical activity, Resuscitation, Syncope, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None
Diagnostic Lab Data:
CDC Split Type: MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1026443

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