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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1026581



Case Details

VAERS ID: 1026581 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-15
Onset:2021-02-04
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: tetanus toxoid
Other Medications: Spironolactone, amlodipine, tamsulosin, losartan, pantoprazole, tadalafil, propranolol
Current Illness: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed.
Preexisting Conditions: Hyperparathyroidism s/p surgical correction in 2020, MGUS, Idiopathic peripheral neuropathy, gout, OSA
Allergies: Erythromycin, PCN, Hmg-coa reductase inhibitors, nifedipine, tetanus toxoids, tetracyclines
Diagnostic Lab Data:
CDC Split Type:

Write-up: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed. No known immediate reaction to vaccination.


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