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

This is VAERS ID 1040877



Case Details

VAERS ID: 1040877 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-02-18
Onset:2021-02-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
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), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: wellbutrin, crestor, albuterol, deltasone, cozaar, spiriva, coreg
Current Illness: chest pain, COPD, Bipolar, dyslipidemia, stage 3 chronic kidney disease
Preexisting Conditions: as above
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown if related to vaccine. patient received 2nd vaccine at 0830, observed 15 minutes, discharged, arrested at 0915 upon entering her home. vaccine was administered by DOH at their community location. patient was pronounced lifeless in the ED.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1040877

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