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

This is VAERS ID 1026752



Case Details

VAERS ID: 1026752 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-03
Onset:2021-02-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Seizure, Ventricular fibrillation, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plavix Furosemide Amiodarone Humulin Lantus Levothyroxine NTG SL Pepsid Spironolactone Alprazolome Isosorbide Trazadone Nystatin topical Hydroxyuria Sertraline
Current Illness:
Preexisting Conditions: Heart Disease Hx of Triple Bypass surgery Atrial Fib CAD Diabetes GERD Hyperlipidemia HTN Hypothyroid Idiopathic Small Intestine Ulcers PAD Polycythemia
Allergies: Ace Inhibitor Allergy Morphine- Adverse Rxn
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed vomiting, seizure and cardiac arrest, V Fib


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