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

This is VAERS ID 1029335



Case Details

VAERS ID: 1029335 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-09
Onset:2021-02-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardio-respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Eplerenone Amiloride KCl Entresto Metolazone Bumex Tamsulosin ASA Docusate prn
Current Illness: none
Preexisting Conditions: Coronary Artery disease with 2 stents Congestive Heart Failure Hyperaldosteronism History of Pulmonary embolus HTN Hyperlipidemia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiopulmonary arrest


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