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

This is VAERS ID 1029554



Case Details

VAERS ID: 1029554 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-17
Onset:2021-02-01
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy       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: 2021-02-01
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.


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