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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1037124



Case Details

VAERS ID: 1037124 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-04
Onset:2021-02-16
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1037124

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